Part two of a three-part series on multiple concussions. Read Prince George teen Brodie Needham's story here.
Before Laurie Cochrane speaks of the symptoms and depression that led to her daughter's death, she pulls photos from an envelope, mostly of Andrea Cochrane as a young woman.
"This is my girl," says Cochrane, smiling.
Here, Andrea grinning at university graduation. Here, on a ski hill, hunched so her racing bib is concealed. And here, standing on a mountain path, the valley beneath and her arms raised skyward.
Andrea died by suicide at age 32. That was almost four years ago.
Since then Cochrane has made it her mission to speak about the dangers of concussion and the importance of treating recovery seriously from day one.
"Andrea can still have an effect on other people by me telling her story because she didn't know what was happening to her. It was very frightening," Cochrane says.
In the last decade of Andrea's life, Cochrane tells the story of a woman struggling to function in her work as a geophysicist and later as she pursued her Master's degree. In her teens, she suffered three concussions in the span of eight months as a downhill ski racer. Then, two more as an adult.
During her first degree, Andrea - an academic overachiever - succeeded despite memory loss and troubles concentrating. For years she quietly dealt with depression, in and out of hospitals for prolonged stays since 2008.
"I don't want this to happen to another family," says Cochrane, a retired nurse.
"If we'd known when she was a teenager about this then our decisions would have been very different, our choices would have been different and Andrea might still be here."
An insidious injury
All three concussions were serious. In all three, Andrea was knocked out after skiing, helmet on.
"Helmets will prevent fracture, they won't prevent concussions," Cochrane says.
Even with the difficulties, Andrea finished her undergraduate degree at the top of her class.
"She looked very stressed, very tired, she didn't look happy when they gave her this big award."
So Cochrane asked her about it.
"And she said 'Mum you have no idea how hard it's been for me,'" Cochrane recalls. "She'd be up all night trying to get assignments done, she had to repeat things over and over to adjust for that loss. Later on we realized she was having absence seizures."
Many people don't realize that's what's happening, Cochrane says, because the person just stares blankly for a brief moment.
"It was incredibly frightening the symptoms she was experiencing," she says. "Even with medication and everything, nothing was really working."
Andrea's work sent her to remote areas for weeks and months at a time and when she returned home, she became increasingly withdrawn. She got another concussion when she rolled a work truck.
"It would take her all night to get work done that would ordinarily take her two hours."
When she came home for Christmas together in 2007, she looked tired and anxious.
"She started to express signs, feelings of helplessness and hopelessness, despair, talking about how hard it was," Cochrane says.
Still, Andrea found ways to function, even volunteering during the 2010 Olympics and later accepted to a Masters program in geophysics at the University of Alberta. But months in, the severe depression, suicidal thoughts and memory loss were back.
"She was isolating herself, withdrawing, embarrassed, ashamed because here's this fiercely independent accomplished young woman not managing anymore. How do you face the world?
"She didn't know how."
By nature Andrea was a problem solver. She kept quiet, stubborn about her ability to cope.
"Kids like that, they are stoic, they are determined, they brush everything off," Cochrane says. "Kids need to know what a concussion is because they won't report it if they don't understand what it is."
Cochrane stresses both cognitive and physical rest for the injured brain.
"That means you shouldn't be going to school, watching TV, using your computer, using your cell phone, texting."
"I watched her deteriorate. It was long and slow and insidious."
Mental health and multiple concussions
Not long before she died, Andrea was released from a months-long stay in the hospital.
Around that time, Cochrane started hearing about Boston University's research on multiple concussions and Andrea's doctors finally had a diagnosis: she had temporal lobe epilepsy, a result of one of her ski racing concussions.
"She phones me and says 'Mum, they think I'm having these seizures because of the concussions,'" Cochrane remembers. "She sounds so relieved that she knows why this is happening to her. She's so relieved."
While the research suggests some correlation between multiple concussions and depression, many caution a definitive connection. Depression, in some studies, is labeled as a strong "predictor," but not a certainty.
"Anyone who sees a lot of patients who have post-concussion syndrome will say the same thing: that depression, sleep disturbance, anxiety - all of these things are greater in that group and often occur," says Dr. Janet Ames, a Prince George specialist, noting often those patients have no family history of mental illness.
Ames refers to a 2012 international consensus on concussions in sport for guidelines on concussion treatment, symptoms and recovery guidelines. Though its focus is on athletes, it notes that those at all levels should be managed the same.
"Mental health issues (such as depression) have been reported as a consequence of all levels of traumatic brain injury including sports-related concussion," it says.
The Zurich consensus calls for physicians to evaluate for symptoms like depression and anxiety "as these symptoms are common in all forms of traumatic brain injury."
"It's one of those grey areas that we're all aware of but it's not entirely clear," said Ames of mental health and multiple concussions. "Should we be treating the depression, say with medication before the brain heals? We just don't have all the answers yet."
Families should be expect mood changes in those concussed, says Ames, recalling how some parents will note their injured son, for example, is "different."
"Of course he's different, he's got a head injury. He's not functioning and so he's getting frustrated, getting depressed, getting irritable, all of these sorts of things."
But saying with certainty that concussions cause depression is still a leap, researchers argue in a Clinical Neuropsychology article from May 2006.
"It is extremely difficult to determine if a person's self-reported symptoms are due to depression, a persistent post-concussion syndrome, or both because many of the symptoms are identical in these conditions" it said. Symptoms include problems with concentration, fatigue, sleep, irritability and headaches.
For Cochrane, it's no question; she says she can clearly connect her daughter's shift in behaviour to that of her injuries. That's why she donated Andrea's brain to Boston University's
"I was like 'This is the missing piece of the puzzle. This is why.'"
Chronic Traumatic Encephalopathy
CTE is a progressive degenerative disease found in people with a history of repeated head injuries, according to the Boston University website.
Cochrane could only donate part of Andrea's brain. Her body was found before Cochrane could identify her, and so the coroner had already completed an examination of the body.
"All they got was a very small part of Andrea's brain and even that was in fragments so they couldn't tell me she had CTE and they couldn't tell me she didn't."
Cochrane, a passionate advocate for concussion education, was invited by Boston University to speak at a conference last year.
Andrea's brain was the first female case and one of the few amateur athletes. By 2009, only 49 cases of CTE had been studied. Boston University's "brain bank" now has more than 200 donors. Of those, 59 of 62 former NFL players had CTE.
Even so, the international concussion consensus says the science isn't settled on CTE causes.
"It was further agreed that CTE was not related to concussions alone or simply exposure to contact sports," it said. "As such, the speculation that repeated concussion or subconcussive impacts cause CTE remains unproven."
Most often, the CTE diagnosis comes after death and in cases of chronic or post-concussion syndrome, MRI and CT scans rarely show structural damage.
Boston University researchers also use caution when discussing depression and CTE.
"Available scientific evidence cannot wholly support the notion that CTE causes suicidal thoughts or behaviors, and such assumptions or assertions should be avoided without further evidence," the authors wrote in a 2014 paper.
Cochrane says watching her daughter suffer all those years is its own evidence.
"There is no doubt in my mind that concussions affected her illness, her health and her death," Cochrane says. "I don't have to be told she had CTE. She fits a lot of the symptoms."
Cochrane tells Andrea's story to anyone who will listen, in part because she thinks the long-term impacts of concussions can be managed, if not prevented, when addressed early.
But that's not the only thing that drives Cochrane.
"It helps me cope with her loss," she says. "I saw her pain and I saw her fear and I saw her confusion and I just know I have to do this for her."
