From the publisher’s rulebook

Who goes first in Cthulhu Realms?

Tasty Minstrel Games English rules, 2015

The player who most recently went insane is the Start Player and takes the first turn.

Read the publisher’s rulebook

Rule details

Play then proceeds clockwise.

For the opening hand, the Start Player draws three cards; other players draw five.

If there’s a tie

The cited starting-player instruction does not specify a tie-break. We don’t infer one.

Source & edition

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Found a different instruction in your edition? Send a correction with the game, edition, and source.