By Moryt Milo
Nothing is more terrifying than watching a family member experience their first psychotic break. Suddenly, parent and adult child are sitting across from a psychiatrist with no clue what comes next.
It begins with everyone getting on the same page, says Dr. Jacob Ballon, a Stanford psychiatrist who specializes in treating individuals with psychotic disorders including schizophrenia. It’s the only way the goals are going to make sense.
It’s different for everyone. It might be resolving symptoms, or wanting to go back to school, improving relationships, or just getting through the day. No matter the reason, it starts with a productive conversation.
“It really requires a good conversation because then we have a North Star to know where we are headed,” says Dr. Ballon, who is also the Associate Chair for Patient Services and co-Division Chief for General Adult Psychiatry and Psychology in the Department of Psychiatry.
Part of that conversation is about choosing the right medication, which is more art than science when it comes to first psychotic episodes. Unless the individual turns out to be resistant to the antipsychotic, initial responses after the first break are robust and work quickly.
Side effects, however, are an ongoing concern, Ballon says, but when the medication is well tolerated the basis of a plan can endure.
“I am always thinking about the side effects of these medications,” Ballon said. “All medications have side effects and until we try it, we don’t know how it might affect the person.”
Many medications cause weight gain and metabolic changes. Some can cause involuntary body movements like Tardive Dyskinesia. Others bring on fatigue, brain fog, or drooling.
When side effects become significant, Ballon explores a different medication depending on the problem. If the patient is nonresponsive to several medications, then the doctor might consider Clozapine. The medication requires regular blood monitoring in the first 18 weeks, but this need is reduced if there is no problem with the white blood cell count.
Is It Forever?
Once the individual starts treatment, Ballon says, it is not uncommon for the patient to ask if they have to take the medication forever. It’s an important question, he says, and a tricky one.
As the psychiatrist, Ballon wants to get out in front of the question—to have a conversation that is honest and open.
“I want this to be a conversation we are not afraid of, otherwise we are going to get past the point where we can’t talk about it. I want to make sure we are talking about it safely.”
The goal of medication is to prevent a second episode, because each subsequent episode makes the brain potentially worse and harder to treat.
He knows that some patients want to taper off their medications, but this too is tricky. The goal is always to avoid a psychotic episode. Through his years of training and reviewing literature, he says, the odds are not great. Studies show that 80% to 90% of people who taper down or go off their medications will have a relapse. That means only 10% to 20% might remain stable.
“It’s important to know a relapse is not based on how long you have taken your medication,” Ballon says.
This is why he wants to see one to two years of no symptoms to determine if the medications were covering something up. You never know when another episode might happen.
Schizophrenia Research Increases
Today, research has ramped up significantly in schizophrenia to find better medications. Early-stage companies are researching better medications with fewer side effects for the illness.
One new medication, Cobenfy, is a game changer. It doesn’t cause weight gain, involuntary body movements, or disrupt the metabolic system. Unlike other antipsychotics, it doesn’t zero in on the D2 dopamine receptor. It’s a completely different approach to schizophrenia. The main side effects are nausea and dry mouth. Getting through the first seven to eight weeks is the key to helping patients adjust.
Cobenfy has shown promise in Ballon’s patients. He has seen better cognition and social interest in them. If insurance companies were more flexible about new medications, Ballon said he’d prefer to suggest it to patients experiencing a first psychotic break.
Other options also include long-acting injectables instead of pills. The benefit being a once-a-month injection versus trying to remember to take pills every day. Studies have also shown lower rehospitalizations on injectables.
Stanford has numerous ongoing research studies in schizophrenia and cognition open to anyone who meets the criteria and there is no charge, and no insurance is required. Some are medication studies, and some are not.
Ballon wants the community to understand schizophrenia has no predictor, no clear biomarker or genetic test, and individuals should check with their doctors about these options. Most offer limited evidence and they can be expensive.
“It hurts my heart when people are throwing money at things that ought to make sense in 2026, but we are just not there,” he says.
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