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Until the day she wrestled a gun from the mouth of her drunken husband, the 37-year-old wife of a Tennessee Army National Guard sergeant thought she was holding it together.
But then the flashbacks started. She began hearing the slide of the weapon repeatedly click into place as she fell asleep and woke from nightmares in which her husband broke windows and punched holes in walls.
Two states away in Texas, at roughly the same time, Renee Ayres, wife of retired Marine Capt. Chris Ayres, also often woke in a cold sweat, dreaming of her husband's blood-soaked bandages or smelling the rank odor of infection. After Chris recovered physically from wounds sustained in Iraq, she dealt with his daily tirades.
Eventually, she "shut down" from family and friends after Chris tried to choke her to death.
And in San Diego, Tim Kahlor, the father of an Iraq War veteran, takes antidepressants to stave off chronic anxiety and worry over his son, diagnosed with severe post-traumatic stress disorder after enduring eight roadside bomb attacks in Iraq.
None of these military family members is a combat veteran, but each carries battle scars of his or her own. The burden of 12 years of war, during which 300,000-plus veterans have been diagnosed with PTSD or clinical depression, has left families with their own mental health conditions.
"PTSD places intolerable stress on the entire family system. … It's like living in hell," said retired Navy psychologist Cmdr. Dennis Reeves, who served in Iraq in 2003.
On Feb. 2, former Marine Eddie Ray Routh confessed to his sister and her husband that he had killed famed Navy SEAL sniper Chris Kyle and friend Chad Littlefield at a Fort Worth, Texas, shooting range.
The Associated Press reported that Routh had been hospitalized twice for PTSD.
The deaths have sent a ripple of fear through the already-stressed community of families and caregivers of active-duty troops and veterans with PTSD. For many, the chilling scenario of a friend or loved one turning on them is their biggest fear.
"When some veterans get to a certain point, they completely black out. When my husband tried to kill himself, he thought he was in Iraq. He was not here. I don't know all the details [of the Routh] case, but the family members … God help them. I've been there," said the Tennessee Guard spouse.
Not all who have PTSD suffer severe, debilitating cases of the condition. But for those who do, their family members endure daily anxiety, depression, anger, fear and other stressful emotions.
According to Pentagon data, PTSD and depression diagnoses have doubled in the military health system since 2006. And in the past seven years, outpatient mental health care visits for active-duty family members have risen by half.
At the Veterans Affairs Department, 6,400 caregivers of severely wounded veterans are eligible for their own health care coverage, including mental health services. Veterans' spouses also can access counseling at VA's 300-plus Vet Centers if their veteran is seen at a center.
But the already overburdened system often has unusually long wait times even for Vet Center counseling.
The Guard wife, who blogs about her own PTSD diagnosis but declined to give her name because she often receives hurtful criticism on Facebook, said she and her husband faced an 18-month wait for marriage counseling at a Vet Center.
"This has been around since wars began, and we didn't learn anything from previous wars … it's a shame we are still having to deal with this," she said.
Medically retired personnel and those with access to Tricare seem slightly better off than families whose troops served shorter periods, because Tricare often covers extensive mental health treatment.
After Renee Ayres' husband was arrested for assault, he received intensive inpatient care for combat PTSD. When he got home from treatment, he realized the depth of his wife's suffering and sent her to an inpatient facility, with Tricare paying all but $10,000 of the cost.
Parents and extended family members like Kahlor often can get treatment through private insurance. His employer, the University of California, San Diego, has full insurance that covers behavioral health and "is very supportive."
But others, like the Guard wife, are not as lucky. She said she called Military OneSource, a phone referral service touted by the Pentagon as its "one-stop shop" for family needs.
But OneSource referred her to VA, which has a facility more than an hour from her home that offered only semiweekly group therapy — at a time when her children arrive home from school.
And she can't leave the kids alone with their father.
"Whatever came off that plane to me was a monster," she said. "I'm supposed to be the rock, and there's nowhere to turn."
A hidden problem
Much has been written about the overburdened VA mental health system and the inability of veterans to access care.
But mental health diagnoses, suicides and suicide attempts by family members of troops and veterans are not tracked by the services or VA, and little is known about the extent of mental health conditions among those who have sent loved ones to war.
"VA is our primary avenue for treating PTSD, but they treat veterans. Insurance companies reimburse to some degree, but [not] for family therapy. The system is inadequate," said Reeves, who recently volunteered his services at the local VA.
After her husband's suicide attempt, the Guard wife fought to get him help. She also began receiving counseling via phone and Internet — a technology Reeves said has finally reached a point where it could serve as a significant solution to the nationwide shortage of mental health practitioners.
Other outlets, such as nonprofit groups like Give an Hour that offer free treatment or therapy, must be better utilized and publicized, he added.
"The burden on the health care system is tremendous," Reeves said. "Community outreach has become critical."
A handful of studies conducted from 2004 to 2007 sought answers on the secondary effects of PTSD on spouses and family members, but more research is needed to define the scope of the problem, advocates say.
Even more important than understanding the issue, they say, is getting treatment to those who need it — parents living with anxiety over their children, children with a parent who is angry all the time, girlfriends, boyfriends and spouses "living with strangers," Reeves said.
"A spouse or significant other cannot survive without their own individual intervention and therapy. They must have it," he said.