Executive Summary

Veterans and first responders occupy high-exposure public roles in which recurrent threat, injury, loss, moral stress, and operational demand can produce enduring psychological and physiological consequences. Current federal estimates identify approximately 17.4 million living Veterans residing in the United States as of September 30, 2025, and Bureau of Labor Statistics occupational categories identify approximately 1.45 million paid police and detectives, paid firefighters, and emergency medical technicians and paramedics. These figures do not fully capture volunteer firefighters or overlap among categories; accordingly, any combined denominator should be treated as a strategic planning estimate rather than a precise census total (National Fire Protection Association [NFPA], n.d.; U.S. Bureau of Labor Statistics [BLS], 2025a, 2025b, 2025c; U.S. Department of Veterans Affairs [VA], 2026a).

The mental health burden in these populations is not limited to posttraumatic stress disorder (PTSD), but PTSD remains a central indicator of need. The VA National Center for PTSD reports that PTSD prevalence varies by service era, health care use, sex, and exposure history. Among Veterans using VA care, current PTSD has been estimated at approximately 13% in national survey data, and VA administrative data for fiscal year 2024 indicate PTSD diagnoses among approximately 14% of men and 24% of women Veterans served by VA (VA National Center for PTSD, 2025a, 2025b). First-responder estimates also vary by occupational subgroup and measurement strategy, but federal and peer-reviewed sources consistently identify elevated risk for PTSD, depression, stress-related impairment, and suicidal thoughts or behaviors relative to the general population (SAMHSA, 2018; Stanley et al., 2016).

Evidence-based psychotherapies for PTSD, including Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing (EMDR), remain first-line interventions and should be represented as such. At the same time, underuse, dropout, partial response, and residual functional impairment create a legitimate public-health rationale for adjunctive and mechanism-focused approaches that target autonomic regulation, sleep, reactivity, and real-world functioning (Hoge et al., 2014; Lang et al., 2024; Schnurr et al., 2024; Steenkamp et al., 2015; Varker et al., 2021).

Autonomic Integration Recovery (AIR®) is a performance-based training intervention designed to strengthen adaptive control over physiological arousal during demanding, high-attention tasks. In a single-arm feasibility study with eight Veterans, all participants completed the intervention and post-intervention assessments, and no adverse physiological or psychological effects were observed within the study procedures. Pre- to post-intervention findings showed a coherent preliminary signal across neurophysiological, symptom, and qualitative domains: seven of eight participants demonstrated increases in peak alpha frequency (PAF), participants reported reductions in trauma-related, anxiety, depressive, and sleep-related symptoms, and qualitative interviews indicated improved bodily awareness, reduced reactivity, and greater perceived capacity to regulate activation under stress.

These results are best interpreted as feasibility and signal-detection findings. They justify a rigorously designed randomized controlled trial (RCT), but they do not establish that AIR® caused the observed changes or that AIR® is superior to existing care. The next phase should test whether AIR® produces durable change relative to an appropriate comparison condition, whether neurophysiological and autonomic markers mediate functional outcomes, and whether the approach generalizes beyond Veterans to first-responder populations.

Public Health Context

High-Exposure Service Populations

The relevant service-exposed population is large, heterogeneous, and difficult to enumerate precisely because Veterans, law enforcement officers, firefighters, emergency medical personnel, and other public safety personnel can overlap. For example, some Veterans become first responders, many firefighters also serve emergency medical functions, and volunteer firefighters are not represented in paid-employment counts. The most defensible public-facing approach is therefore to report population estimates by category, explicitly note overlap, and avoid presenting a single summed denominator as if it were a census figure.

Population estimate anchors

Several population anchors are relevant to the AIR® public-health rationale. Current VA materials estimate 17.4 million living Veterans residing in the United States, with the estimate tied to September 30, 2025. Bureau of Labor Statistics occupational profiles list approximately 826,800 paid police and detective jobs, 344,900 paid firefighter jobs, and 282,900 emergency medical technician and paramedic jobs. These paid occupational categories provide a conservative first-responder denominator, but they do not capture all public-safety roles. The paid firefighter estimate is particularly conservative because BLS notes that volunteer firefighters are excluded from the occupational employment profile (U.S. Bureau of Labor Statistics [BLS], 2025a, 2025b, 2025c; U.S. Department of Veterans Affairs [VA], 2026a).

A broader fire-service estimate from the National Fire Protection Association identifies approximately 1,018,100 career and volunteer firefighters in 2023. This estimate is useful for contextualizing first-responder need, but it should not be added to the BLS paid-firefighter number without deduplication. For public-facing language, the most defensible formulation is that the United States includes approximately 17.4 million Veterans and at least 1.45 million paid first responders in the three core occupational categories, with the broader first-responder population substantially larger when volunteer and adjacent public-safety roles are included (BLS, 2025b; National Fire Protection Association

Population estimate anchors

Several population anchors are relevant to the AIR® public-health rationale. Current VA materials estimate 17.4 million living Veterans residing in the United States, with the estimate tied to September 30, 2025. Bureau of Labor Statistics occupational profiles list approximately 826,800 paid police and detective jobs, 344,900 paid firefighter jobs, and 282,900 emergency medical technician and paramedic jobs. These paid occupational categories provide a conservative first-responder denominator, but they do not capture all public-safety roles. The paid firefighter estimate is particularly conservative because BLS notes that volunteer firefighters are excluded from the occupational employment profile (U.S. Bureau of Labor Statistics [BLS], 2025a, 2025b, 2025c; U.S. Department of Veterans Affairs [VA], 2026a).

A broader fire-service estimate from the National Fire Protection Association identifies approximately 1,018,100 career and volunteer firefighters in 2023. This estimate is useful for contextualizing first-responder need, but it should not be added to the BLS paid-firefighter number without deduplication. For public-facing language, the most defensible formulation is that the United States includes approximately 17.4 million Veterans and at least 1.45 million paid first responders in the three core occupational categories, with the broader first-responder population substantially larger when volunteer and adjacent public-safety roles are included (BLS, 2025b; National Fire Protection Association [NFPA], n.d.).

Burden of PTSD, Depression, and Regulatory Dysregulation

The clinical burden among Veterans and first responders is best conceptualized as a convergent pattern of trauma-related symptoms, depressive symptoms, anxiety, sleep disruption, autonomic dysregulation, and impaired role functioning rather than as a single diagnostic category. VA sources show that PTSD prevalence among Veterans varies meaningfully by era and health care engagement. Current PTSD has been estimated at 13% among Veterans who use VA care and 4% among Veterans who do not use VA care, and the VA reported fiscal year 2024 PTSD diagnoses in 14% of men and 24% of women Veterans served by VA (VA National Center for PTSD, 2025a, 2025b).

First-responder data are less centralized in the United States, but federal and peer-reviewed sources indicate substantial behavioral health exposure. SAMHSA (2018) summarized evidence that first responders are at increased risk for PTSD, depression, stress, substance use, and suicidal ideation. Systematic reviews and large public safety personnel studies likewise indicate elevated symptom burden, although prevalence estimates differ across countries, occupational subgroups, measurement instruments, and sampling methods (Berger et al., 2012; Carleton et al., 2018; Stanley et al., 2016).

Across both populations, residual symptoms often involve chronic hyperarousal, emotional reactivity, poor sleep initiation, reduced stress tolerance, somatic vigilance, and difficulty reengaging in meaningful activity. These symptom clusters align with literature on PTSD-related sleep disturbance, neurovisceral integration, and heart-rate variability as a marker of autonomic regulation (Germain, 2013; Schneider & Schwerdtfeger, 2020; Thayer & Lane, 2000).

Treatment Engagement and Residual Need

The availability of evidence-based treatment is a strength of the current care landscape. The 2023 VA/DoD guideline and related clinical summaries recommend CPT, EMDR, and PE as individual, manualized, trauma-focused psychotherapies for PTSD (Lang et al., 2024; Schnurr et al., 2024; VA/DoD Management of PTSD and ASD Work Group, 2023). The rationale for AIR® should therefore not be framed as a replacement for established treatments. A more scientifically and ethically defensible position is that AIR® may represent a candidate adjunctive or complementary mechanism-focused training model for individuals with residual dysregulation, performance impairment, sleep disruption, or incomplete recovery after standard care.

Unmet need remains substantial because treatment initiation, retention, and remission are not universal. Hoge et al. (2014) found that treatment reach for PTSD after combat deployment remained low to moderate, with many soldiers either not accessing care or not receiving minimally adequate care. In the broader U.S. population, Wang et al. (2005) found that only 41.1% of adults with 12-month mental disorders received any treatment during the prior year. In randomized trials of guideline-recommended PTSD treatments, Varker et al. (2021) estimated an overall dropout rate of 20.9%, with higher dropout among military and Veteran populations. Reviews of military-related PTSD trials also indicate that trauma-focused treatments can produce clinically meaningful improvement while leaving many patients with residual symptoms or diagnostic status (Steenkamp et al., 2015).

Suicide Outcomes and Public-Health Consequences

The consequences of persistent trauma-related and depressive conditions include occupational impairment, family disruption, substance-use risk, cardiovascular strain, and suicide. The 2025 National Veteran Suicide Prevention Annual Report indicates that 6,398 Veterans died by suicide in 2023, corresponding to an average of 17.5 Veteran suicide deaths per day and a suicide rate of 35.2 per 100,000 Veterans (VA, 2026b). These data support the need for prevention, early intervention, evidence-based treatment, and sustained post-treatment functional recovery.

First-responder suicide surveillance is improving but remains less centralized than Veteran suicide reporting. A CDC/NIOSH communication noted that law enforcement officers and firefighters have been reported to die by suicide more often than in the line of duty and that emergency medical services providers have elevated suicide risk relative to the general public (CDC/NIOSH, 2021). A National Violent Death Reporting System analysis of 2015-2017 data found that first responders accounted for 1% of suicides in the analytic dataset and identified occupation-specific patterns across law enforcement, firefighters, emergency medical services clinicians, and public safety telecommunicators (Carson et al., 2023). These findings argue for better surveillance, targeted prevention, and interventions that are acceptable to personnel who may be reluctant to seek conventional care.

Autonomic Integration Recovery (AIR®)

Intervention Rationale

AIR® is conceptualized as a structured performance-training intervention rather than as a conventional trauma-processing psychotherapy. Its target is adaptive regulation under activation: the capacity to maintain attention, physiological steadiness, and behavioral choice while the individual is engaged in demanding tasks. This rationale is consistent with neurovisceral models that link prefrontal, attentional, and autonomic regulation to emotion regulation and flexible responding (Thayer & Lane, 2000).

The feasibility study emphasized peak alpha frequency as one objective neurophysiological marker. PAF should be interpreted cautiously. It is not a stand-alone biomarker of recovery, and it should not be presented as diagnostic. However, prior studies have associated individual alpha frequency with cognitive processing speed, attention, and cognitive performance, and PAF has been studied as a candidate physiological parameter in PTSD research (Klimesch, 1996, 1999, 2012; Rathee et al., 2020; Wahbeh & Oken, 2013). Therefore, PAF is a plausible mechanism-adjacent marker for hypothesis generation in a feasibility study and an appropriate candidate measure for confirmatory testing in an RCT.

Feasibility Study Design

A single-arm feasibility study was conducted with eight Veterans to determine whether AIR® could be implemented safely and whether it generated interpretable preliminary signals across neurophysiological, symptom, and qualitative domains. Participants completed pre- and post-intervention assessments that included objective neurophysiological measurement, standardized self-report instruments, and structured qualitative interviews. The study was designed for feasibility and signal detection rather than efficacy testing.

For website publication, the study summary should include the following methods details when available: recruitment source; inclusion and exclusion criteria; demographic characteristics; intervention dose, frequency, and duration; standardized measures; neurophysiological acquisition and preprocessing procedures; adverse-event monitoring procedures; missing-data handling; and oversight by an institutional review board or comparable ethics process. Providing these details will strengthen credibility without overstating the conclusions.

Feasibility and Safety Outcomes

All eight Veterans completed the AIR® program and post-intervention assessment procedures. No adverse physiological or psychological effects were observed within the study procedures. In feasibility terms, this pattern supports preliminary acceptability, retention, and procedural tolerability. It does not, by itself, establish safety across broader or higher-risk populations; larger trials should use formal adverse-event definitions, monitoring intervals, and stopping rules.

Preliminary Neurophysiological Signal

Seven of eight participants demonstrated increases in PAF from pre- to post-intervention assessment. Increases were observed across frontal, central, temporal, and posterior regions, suggesting a distributed regulatory signal rather than a localized or compensatory effect. Within-subject effect-size estimates may be useful for planning a larger trial, but the absence of a randomized comparator means that the observed change cannot be attributed causally to AIR®. The most defensible conclusion is that AIR® was associated with a coherent pre/post neurophysiological signal that warrants confirmatory testing.

Preliminary Symptom and Functional Signals

Participants also demonstrated reductions in trauma-related symptoms, anxiety, depressive symptoms, and sleep-related difficulty, including improved sleep initiation and nighttime physiological settling. These changes were not accompanied by increased somatic complaints or reported maladaptive coping. The convergence of symptom and regulatory indicators is clinically meaningful as a feasibility signal, but it remains subject to expectancy effects, regression to the mean, repeated measurement, spontaneous recovery, concurrent care, and the nonspecific effects of structured attention and support.

Qualitative Experience

Qualitative interviews indicated improved bodily awareness, reduced reactivity, and greater perceived ability to regulate physiological activation in real time. Participants described an enhanced capacity to pause, maintain clarity, and choose responses under stress. Several narratives suggested transfer of training principles to work demands, interpersonal situations, and pre-sleep routines. These qualitative findings strengthen the ecological plausibility of the intervention because they describe changes in self-regulation as lived experience rather than only as score change.

Bounded interpretation of feasibility findings

The feasibility findings are best expressed by domain. In the completion and tolerability domain, all eight Veterans completed the program and post-assessment, and no adverse physiological or psychological effects were observed within the study procedures. This supports preliminary feasibility and procedural tolerability, but a larger sample with prespecified adverse-event monitoring is required before making broader safety claims.

In the neurophysiological domain, seven of eight participants showed increased PAF. This suggests a coherent pre/post regulatory signal, but randomization, standardized or blinded EEG procedures, and prespecified PAF analysis are needed before mechanism claims can be made.

In the symptom and sleep domain, participants showed reductions in trauma-related, anxiety, depressive, and sleep-related symptoms. These changes suggest a promising clinical signal, but they do not establish causal effect; confirmation requires an appropriate comparison condition, validated outcomes, follow-up, and intention-to-treat analyses.

In the qualitative functioning domain, participants reported improved body awareness, lower reactivity, and transfer of strategies to daily life. These observations support acceptability and ecological plausibility, but they should be tested in a mixed-methods design with systematic qualitative coding, triangulation, and subgroup analysis.

Across all domains, the interpretive language should distinguish feasibility signals from efficacy conclusions.

Interpretation of the Feasibility Findings

What the Findings Support

The findings support three preliminary conclusions. First, AIR® appears feasible to deliver to a small Veteran sample, as reflected by full completion and post-assessment retention. Second, the intervention was associated with convergent signals across neurophysiology, symptoms, sleep, and lived experience. Third, the direction and coherence of the findings justify progression to a controlled trial designed to test efficacy, durability, and mechanism.

The most scientifically accurate summary is therefore as follows: In a small, uncontrolled feasibility study, AIR® was associated with coherent pre/post changes in regulatory, symptom, and qualitative domains. These findings warrant a fully powered RCT to determine whether AIR® produces reliable clinical and functional benefit beyond nonspecific effects, expectancy, repeated measurement, and concurrent care.

What the Findings Do Not Yet Support

The feasibility study does not support claims that AIR® has proven efficacy, that it is superior to PE, CPT, EMDR, medication, or usual care, or that it prevents suicide. It also does not establish that observed PAF changes caused symptom improvement. Such claims require randomized comparison, adequate statistical power, prespecified primary outcomes, blinded assessment where feasible, systematic adverse-event monitoring, and longitudinal follow-up. The distinction is important: restrained interpretation enhances scientific credibility and reduces reputational risk when the paper is posted publicly.

Strategic Implications

The findings have three strategic implications for the next phase of research and implementation. First, regulatory capacity may be a clinically meaningful target that can be measured directly rather than inferred solely from symptom reduction. Second, physiological activation may be trained toward functional engagement rather than conceptualized only as a symptom to suppress. Third, objective markers such as PAF, when paired with validated symptom measures and qualitative data, may help define mechanism-focused endpoints for a larger trial.

These implications should be presented as hypotheses generated by feasibility data, not as definitive discoveries. The public-facing message can be strong without being overstated: AIR® has generated a coherent feasibility signal in Veterans and is ready for rigorous validation.

Recommended Next Phase:
Randomized Controlled Trial

The next phase should be a fully powered RCT that follows reporting and design principles for pilot-to-definitive trial progression. Pilot and feasibility guidance emphasizes that early studies should clarify feasibility, acceptability, procedures, and trial readiness, whereas definitive trials are required to test efficacy (Eldridge et al., 2016; Lancaster & Thabane, 2019). The RCT should incorporate an appropriate comparison condition, standardized assessment procedures, longitudinal follow-up, and prespecified analytic models.

Conclusion

Veterans and first responders remain at elevated risk for trauma-related symptoms, depression, sleep disturbance, regulatory dysregulation, and suicide-related outcomes. Evidence-based treatments are essential and should remain central to care. However, ongoing treatment gaps and residual functional impairment create a compelling rationale for adjunctive interventions that directly target adaptive regulation under demand. In a small single-arm feasibility study, AIR® was associated with full completion, no observed adverse effects within study procedures, increases in PAF in seven of eight Veterans, reductions in symptom indicators, and qualitative reports of improved real-time regulation. The appropriate conclusion is not that AIR® has been proven effective, but that AIR® has produced a coherent feasibility signal that warrants a rigorous randomized controlled trial.