No Evidence for Cognitive Decline in First-Episode Psychosis: A Meta-Analysis of Long-Term Longitudinal Studies

Cognitive deficits are central to schizophrenia-spectrum disorders and already present in many patients at first-episode psychosis (FEP). Prior meta-analyses suggest cognitive deficits remain relatively stable, but most of them tracked patients for only a few years and rarely compared trajectories directly with matched healthy controls (HCs). We aimed to characterize cognitive trajectories over long-term follow-ups.

Following PRISMA-2020 guidelines, we searched databases for longitudinal studies of cognition in recent-onset psychosis. Forty-nine datasets (3693 FEP and 1399 HCs) were included, with follow-ups ranging from 2 to 25 years. Random-effects meta-analyses quantified within-group change (FEP and HC separately) and between-group differences (FEP-vs.-HC) across short (2-5 years), mid (5-10 years), and long-term (≥10 years) intervals. Meta-regressions examined the influence of clinical moderators.

Both FEP patients and HCs showed either stable performance or small effect-size improvements in global (FEP: d = 0.22, P < .0001) and domain-specific cognition over long-term, with no evidence of progressive deterioration. Direct comparisons revealed no FEP-vs.-HC differences in global cognitive change overall (d = 0.05, P = .568) or within any follow-up interval (short, mid, and long). Across domains, the only exception was attention, where patients improved compared to controls. Changes in positive and negative symptoms were unrelated to changes in global cognition.

Neuropsychological performance in FEP remains stable for at least a decade, with modest gains largely attributable to practice effects and no sign of neurodegenerative decline. These trait-like deficits appear partly independent of long-term symptom changes, and further support neurodevelopmental over neurodegenerative models of schizophrenia.