The comparative study of cognitive function in patients with first-episode schizophrenia versus chronic schizophrenia occupies a vital space within psychiatric research, as cognitive deficits are considered a central feature of schizophrenia and major determinants of social and occupational outcomes.[1] Schizophrenia is a heterogeneous disorder characterized not only by positive and negative symptoms but also by pronounced disturbances in attention, working memory, executive functioning, verbal learning, and processing speed.[2] These cognitive impairments play a significant role in illness course and functional prognosis.[3] Several decades of research have established that cognitive deficits are present even before the onset of overt psychotic symptoms, often predating the initial clinical episode by years. [2]Early longitudinal studies show that children or adolescents who later develop schizophrenia exhibit lower cognitive performance than their healthy peers, especially in domains like nonverbal reasoning and working memory.[3]The severity and nature of these impairments may foreshadow the risk for developing schizophrenia and shape the clinical presentation at the time of first-episode psychosis.[1] Patients experiencing their first episode of schizophrenia typically demonstrate broad cognitive dysfunction across domains such as executive functions, memory, attention/vigilance, and psychomotor speed. These deficits are generally comparable to those observed in chronic schizophrenia, though some longitudinal studies suggest only mild increases in the frequency or severity of impairment in chronically affected patients. For instance, a comprehensive synthesis of literature from 2009 to 2022 concluded that globally decreased cognitive functioning is present in psychotic disorders from the first episode onward—with relatively stable or mildly progressive deficits into later chronic stages. This stability challenges earlier assumptions of rapid cognitive decline post-first episode, with modern research highlighting a continuum of persistent impairment rather than acute worsening.[1,3] The distinction between first-episode and chronic schizophrenia vis-à-vis cognitive functioning is nuanced. First-episode patients may already show widespread problems, and chronic patients often retain similar profiles, though some may exhibit subtle worsening due to long-term effects of illness and other factors like aging, cumulative antipsychotic exposure, or comorbidities. The debate continues regarding the degree to which chronic schizophrenia involves progressive deterioration versus arrested neurodevelopmental trajectories, but most reviews suggest that the magnitude of further decline after the initial episode may be modest, with notable individual variability.[1-3] Importantly, cognitive impairment is not only a diagnostic hallmark but a therapeutic target. Interventions to address these deficits are increasingly recognized as essential components of comprehensive schizophrenia treatment strategies, given their profound impact on real-world functioning, social integration, and overall prognosis. Consequently, a deeper understanding of cognitive trajectories from the first episode through chronic stages is critical for optimizing individualized care and tailoring cognitive remediation therapies.[1,3] Cognitive deficits in schizophrenia are pervasive, emerging before the first episode and persisting into chronicity, with only modest progression in most cases. [2] The comparative study of cognitive profiles between first-episode and chronic schizophrenia thus provides key insights into illness mechanisms, risk prediction, and evidence-based interventions to improve functional outcomes in this patient population.[1,3]

This comparative, cross-sectional observational study was conducted in the Department of Psychiatry, Hind Medical College, Lucknow, from November, 2022, to October, 2023. The study enrolled a total of 90 patients diagnosed with schizophrenia, grouped into those experiencing their first episode and those with chronic schizophrenia, in accordance with Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Sample Selection Participants were recruited from the psychiatry outpatient department after screening for eligibility. Inclusion criteria comprised patients aged 18-60 years, a formal diagnosis of schizophrenia, and provision of informed consent. Exclusion criteria included comorbid neurological illness, substance dependence, intellectual disability, and other conditions impacting cognitive function (e.g., diabetes, chronic alcoholism, major neurocognitive disorders). Group Classification Patients were classified as “first-episode” if presenting within one year of onset of psychotic symptoms and without prior long-term antipsychotic treatment. “Chronic” schizophrenia patients had a history exceeding two years since diagnosis and continuous antipsychotic therapy for at least one year. Assessment Tools The study evaluated cognitive function using the Mini Mental State Examination (MMSE) and Addenbrooke’s Cognitive Examination-Revised (ACE-R), both validated for neurocognitive assessment in schizophrenia. The MMSE addresses orientation, memory, attention, calculation, language, and visuospatial skills, with a maximum score of 30. ACE-R covers attention/orientation, memory, fluency, language, and visuospatial abilities, yielding a total score up to 100. Higher scores indicate better cognitive functioning. Demographic and clinical data were collected using a semistructured proforma, including age, gender, education, occupation, symptom duration, and treatment history. Psychiatric symptom severity was appraised using the Positive and Negative Symptom Scale (PANSS), where applicable. Procedure After securing institutional ethics committee approval and written informed consent, eligible patients completed all cognitive and clinical assessments during scheduled outpatient visits in a quiet, standardized environment. Assessments were administered in a fixed order, and patients were advised to abstain from stimulant beverages or smoking for at least 12 hours prior. The last antipsychotic dose was taken at least 12 hours before cognitive testing to minimize acute medication effects. Data Analysis All collected data were anonymized and entered into a secured database. Continuous variables were summarized as mean ± standard deviation, while categorical variables were expressed as percentages. Between-group comparisons of cognitive scores were performed using Student’s t-test or Mann–Whitney U test for non-parametric data. Chi-square tests were used for categorical variables. Statistical significance was set at p < 0.05. Univariate logistic regression was used to identify associations between clinical parameters and cognitive outcomes.

The results of the study highlight significant differences between first-episode and chronic schizophrenia groups across multiple domains. Participants with first-episode schizophrenia had a much lower mean age (25.3 ± 4.2 years) compared to the chronic group (38.7 ± 6.1 years), a difference that reached high statistical significance (t = 5.82, p < 0.001). Gender distribution was similar between groups, with males comprising 60% and 62% of the first-episode and chronic groups, respectively, showing no significant difference (χ² = 0.04, p = 0.83). Duration of illness strongly differentiated groups, as expected, with first-episode participants reporting a mean duration of 0.8 ± 0.4 years, while chronic cases averaged 10.3 ± 3.2 years (p < 0.001). Educational attainment (≥ 10 years formal schooling) was more frequent among first-episode subjects (84%) compared to chronic (60%; χ² = 6.52, p = 0.01). Socioeconomic status, family history of psychosis, and marital status revealed mixed trends, notably a greater proportion of singles in the first-episode group (71%) compared to 40% in the chronic group (χ² = 8.57, p = 0.004) [Table 1]. Clinical characteristics also varied substantially. Mean duration of untreated psychosis was measurable only in the first-episode group (5.4 ± 3.1 months). PANSS positive scores were higher in first-episode (18.7 ± 4.5 vs. 16.3 ± 5.6; p = 0.06), while negative scores were significantly greater in chronic schizophrenia (22.9 ± 6.1 vs. 14.8 ± 5.2; p < 0.001). CGI severity scores (mean 4.1 vs. 5.0; p < 0.01), antipsychotic dose (312 ± 118 mg/day vs. 458 ± 159 mg/day; p < 0.01), and the prevalence of extrapyramidal side effects (18% vs. 38%; χ² = 4.30, p = 0.04) were all significantly higher in the chronic group [Table 2]. Cognitive domain analysis demonstrated that first-episode patients consistently outperformed chronic schizophrenia patients. Verbal memory, working memory, executive function, and processing speed scores were all significantly higher in the first-episode group (e.g., verbal memory: 72.4 ± 10.2 vs. 62.1 ± 9.8, p < 0.01). Attention and concentration scores were higher in first-episode cases but did not reach statistical significance (74.1 ± 7.8 vs. 68.6 ± 9.2, p > 0.05). The total composite cognitive score highlighted overall better functioning in first-episode schizophrenia (73.1 ± 6.8) versus chronic (64.9 ± 7.9; p < 0.01) [Table 3]. All findings support the pattern that cognitive deficits are more pronounced in chronic schizophrenia across several domains, further corroborated by demographic and clinical feature disparities, with cognition appearing to decline in parallel with disease chronicity and severity [Table 1][Table 2][Table 3]. Table 1. Demographic Profile of Study Participants (n = 90) Variable First‑Episode Schizophrenia (n = 45) Chronic Schizophrenia (n = 45) Statistical Significance Mean Age (years) 25.3 ± 4.2 38.7 ± 6.1 t = 5.82, p < 0.001 Gender (Male/Female) 27 / 18 (60 % / 40 %) 28 / 17 (62 % / 38 %) χ² = 0.04, p = 0.83 Mean Duration of Illness (years) 0.8 ± 0.4 10.3 ± 3.2 p < 0.001 Educational Level (≥ 10 years schooling) 38 (84 %) 27 (60 %) χ² = 6.52, p = 0.01 Socioeconomic Status (Middle class) 30 (67 %) 28 (62 %) p = 0.64 Family History of Psychosis 12 (27 %) 15 (33 %) p = 0.51 Marital Status (Single/Married) 32 / 13 (71 % / 29 %) 18 / 27 (40 % / 60 %) χ² = 8.57, p = 0.004 Table 2. Clinical Characteristics of Study Groups Clinical Variable First‑Episode Schizophrenia (n = 45) Chronic Schizophrenia (n = 45) Statistical Significance Mean Duration of Untreated Psychosis (months) 5.4 ± 3.1 NA — PANSS Positive Score (mean ± SD) 18.7 ± 4.5 16.3 ± 5.6 p = 0.06 PANSS Negative Score (mean ± SD) 14.8 ± 5.2 22.9 ± 6.1 p < 0.001 CGI Severity Score (mean ± SD) 4.1 ± 0.9 5.0 ± 0.8 p < 0.01 Antipsychotic Dose (chlorpromazine equivalent mg/day) 312 ± 118 458 ± 159 p < 0.01 Extrapyramidal Side Effects (Present %) 8 (18 %) 17 (38 %) χ² = 4.30, p = 0.04 Table 3. Cognitive Function Domain Scores (Mean ± SD) Cognitive Domain First‑Episode Schizophrenia (n = 45) Chronic Schizophrenia (n = 45) p‑value Verbal Memory 72.4 ± 10.2 62.1 ± 9.8 < 0.01 Working Memory 75.6 ± 8.7 67.3 ± 10.5 < 0.05 Executive Function 70.5 ± 9.0 61.0 ± 11.4 < 0.01 Attention and Concentration 74.1 ± 7.8 68.6 ± 9.2 > 0.05 Processing Speed 73.2 ± 8.9 65.4 ± 9.6 < 0.05 Total Composite Cognitive Score 73.1 ± 6.8 64.9 ± 7.9 < 0.01

The results of the present study demonstrate substantial differences in cognitive and clinical profiles between first-episode and chronic schizophrenia patients, which correspond closely with data from prior research. The finding that mean age was significantly lower in first-episode cases, with chronic patients showing longer illness duration and higher rates of being married, is consistent with the demographic patterns reported by Talreja et al.,[4] who observed similar age and education gradients between acute and chronic schizophrenia cohorts. Clinical characteristics, including higher antipsychotic doses and more pronounced extrapyramidal side effects in chronic schizophrenia, align with earlier studies addressing illness chronicity and treatment impacts.[1] Notably, first-episode patients exhibited higher PANSS-positive scores, while chronic cases showed increased PANSS-negative scores and CGI severity, echoing Peng et al.'s[5] findings that negative symptoms and chronicity correlate with broader cognitive impairment and greater severity of clinical pathology. Most critically, the observed pattern of superior cognitive functioning in first-episode schizophrenia, across domains such as verbal memory, executive function, working memory, and processing speed, reflects the “global decrease” hypothesis described by Tschentscher et al.,[1] who found cognitive impairments present in all domains from the first episode onward but with only mild progression in chronic illness stages. This continuum of impairment—from early onset to chronic schizophrenia—matches both longitudinal and cross-sectional studies showing persistent but gradually worsening cognitive deficits as disease advances. Further corroboration is seen in research by Talreja et al.[4] and Peng et al.,[5] both of whom identified marked deterioration in memory, attention, and executive functioning in chronic schizophrenia compared to first-episode presentations. Peng et al.[5] specifically highlighted negative symptoms’ association with cognitive deficits in first-episode patients, while Tschentscher et al.[1] argued that therapeutic intervention should address cognitive impairment already significant in early disease stages. Collectively, these studies reinforce the current findings: cognitive impairment is a core feature of schizophrenia evident in both early and late stages, intensifying with chronicity and greater negative symptom burden. Demographic and clinical factors—including age, marital status, and educational level—modulate these trajectories, but global cognitive decline remains a defining characteristic throughout the illness course.

The study illustrates that cognitive impairment is a pervasive feature of schizophrenia, evident from the first episode itself and showing greater severity in chronic cases. First-episode patients demonstrate consistently better performance across cognitive domains such as verbal memory, working memory, executive function, and processing speed when compared to those with chronic illness. These findings, along with differences in demographic and clinical profiles, underscore the impact of illness duration and chronicity on overall cognitive decline. The results emphasize the importance of timely intervention and ongoing cognitive assessment in schizophrenia, as early deficits tend to persist and worsen, ultimately influencing functional outcomes and quality of life.

1. Tschentscher N et al. Neurocognitive Deficits in First-Episode and Chronic Psychotic Disorders: A Systematic Review. Neuropsychiatric Disease and Treatment. 2023;19:491–508. 2. McCutcheon RA et al. Cognitive impairment in schizophrenia: aetiology, pathophysiology, and treatment implications. 2023. 3. Meyer-Lindenberg A et al. Cognitive Impairment Associated with Schizophrenia. Annual Review Pharmacology & Toxicology. 2023. 4. Talreja BT et al. Cognitive function in schizophrenia and its association with sociodemographic factors. Indian J Psychiatry. 2013;55(1):41-46. 5. Peng XJ et al. The Association Between Cognitive Deficits and Clinical Characteristics in First-Episode Drug-Naïve Schizophrenia Patients. Front Psychiatry. 2021;12:638773.