National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×
Returning Home from Iraq and Afghanistan:
Assessment of Readjustment Needs of
Veterans, Service Members, and Their
Families

Committee on the Assessment of Readjustment Needs of Military Personnel,
Veterans, and Their Families

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract HHSP23320042509XI between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project.

International Standard Book Number-13: 978-0-309-26427-3
International Standard Book Number-10: 0-309-26427-8

Additional copies of this report are available from the National Academies Press, 500 Fifth Street NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313 http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2013 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

IOM (Institute of Medicine). 2013. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

Knowing is not enough; we must apply.
Willing is not enough; we must do.

—Goethe

image

INSTITITE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
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COMMITTEE ON THE ASSESSMENT OF READJUSTMENT NEEDS OF MILITARY PERSONNEL, VETERANS, AND THEIR FAMILIES

image

GEORGE W. RUTHERFORD, MD, AM (Chair), Salvatore Pablo Lucia Professor and Vice Chair, Department of Epidemiology and Biostatistics; Director, Prevention and Public Health Group, Global Health Sciences, University of California, San Francisco

MARGARITA ALEGRÍA, PhD, Professor, Department of Psychiatry, Harvard Medical School; Director, Center for Multicultural Mental Health Research, Cambridge Health Alliance

JEFFREY J. BAZARIAN, MD, MPH, Associate Professor, University of Rochester Medical Center

DAN G. BLAZER, MD, PhD, J.P. Gibbons Professor of Psychiatry, Duke University Medical Center

KATHLEEN M. CARROLL, PhD, Professor of Psychiatry, Department of Psychiatry, Division of Substance Abuse, Yale University

IBOLJA CERNAK, MD, PhD, ME, MHS, Chair, Canadian Military and Veterans’ Clinical Rehabilitation Medicine, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada

JOHN D. CORRIGAN, PhD, Professor and Director, Division of Rehabilitation Psychology, Department of Physical Medicine and Rehabilitation, Ohio State University

E. JANE COSTELLO, PhD, Professor, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine

SUREYYA S. DIKMEN, PhD, Professor, Department of Rehabilitation Medicine, University of Washington

NAIHUA DUAN, PhD, Professor of Biostatistics (in Psychiatry), Department of Psychiatry, Columbia University

RYAN D. EDWARDS, PhD, Associate Professor of Economics, Queens College and the Graduate Center, City University of New York; Research Associate, National Bureau of Economic Research, Cambridge, MA

CHRISTINE EIBNER, PhD, Economist, RAND Corporation

NORAH C. FEENY, PhD, Professor, Department of Psychological Sciences, Case Western Reserve University

SANDRO GALEA, MD, DrPH, Gelman Professor and Chair, Department of Epidemiology, Columbia University Mailman School of Public Health

GREGORY C. GRAY, MD, MPH, Professor and Chair, Department of Environmental and Global Health, College of Public Health and Health Professions; Director, Global Pathogens Laboratory, University of Florida

KENNETH W. KIZER, MD, MPH, Distinguished Professor, University of California, Davis, School of Medicine and Betty Irene Moore School of Nursing; Director, Institute for Population Health Improvement, University of California, Davis, Health System

MEREDITH A. KLEYKAMP, PhD, Assistant Professor of Sociology, University of Maryland

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

JANICE L. KRUPNICK, PhD, Professor of Psychiatry and Director, Trauma and Loss Program, Department of Psychiatry, Georgetown University School of Medicine

RICHARD A. KULKA, PhD, Consultant, Statistical, Survey and Social Research

BENNETT L. LEVENTHAL, MD, Deputy Director, Nathan Kline Institute for Psychiatric Research; Professor, Department of Disability and Human Development, University of Illinois at Chicago; Irving B. Harris Professor, Emeritus, The University of Chicago

ALAIR MACLEAN, PhD, Associate Professor, Department of Sociology, Washington State University, Vancouver

FRANCES MURPHY, MD, MPH, Health Care Independent Consultant, Silver Spring, MD

SAMUEL J. POTOLICCHIO, MD, Professor of Neurology, Department of Neurology, George Washington University Medical Center

SCOTT L. RAUCH, MD, Chair, Partners Psychiatry and Mental Health; President and Psychiatrist in Chief, McLean Hospital; Professor of Psychiatry, Harvard Medical School

WILLIAM E. SCHLENGER, PhD, Principal Scientist, Abt Associates Inc.

TYLER SMITH, MS, PhD, Associate Professor, Department of Community Health, School of Health and Human Services, National University Technology and Health Sciences Center

S.V. SUBRAMANIAN, PhD, Professor of Population Health and Geography, Department of Society, Human Development, and Health, Harvard School of Public Health

SHELLEY MACDERMID WADSWORTH, PhD, Professor of Human Development and Family Studies; Director, Center for Families; Director, Military Family Research Institute, Purdue University

ALBERT W. WU, MD, MPH, Professor and Director, Center for Health Services and Outcomes Research, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

STUDY STAFF

image

CAROLYN FULCO, Scholar

LAURA AIUPPA DENNING, Senior Program Officer

HARRIET CRAWFORD, IT Project Manager

CARY HAVER, Senior Program Associate

RENÉE WLODARCZYK, Senior Program Associate

DWAYNE BELL, Programmer/Analyst

MARC MEISNERE, Research Associate

JOE GOODMAN, Senior Program Assistant

JONATHAN SCHMELZER, Senior Progam Assistant

NORMAN GROSSBLATT, Senior Editor

CATHERINE A. GRUBER, Editor

CHRISTIE BELL, Financial Officer (until January 2012)

GARY WALKER, Senior Financial Officer (until November 2012)

DORIS ROMERO, Financial Associate

FREDRICK ERDTMANN, Director, Board on the Health of Select Populations

ANALYSTS, CONSULTANTS, AND WRITERS

MARK BREWSTER, Columbia University

CONNIE CITRO, National Research Council

GREG COHEN, Columbia University

RUTH CROSSGROVE, Independent Editor

MIRIAM DAVIS, Independent Consultant

PETER JAMES, Harvard University

JOAN MACHAMER, University of Washington

ELLEN MANTUS, National Research Council

SUE MARCUS, Columbia University

MARTHA PRESCOTT, Columbia University

THERESA SCHWARTZ, Research Foundation for Mental Hygiene

ANDREA SOLARZ, Independent Consultant

JAMES WEAVER, Research Foundation for Mental Hygiene

WESTAT Staff: Stephanie Beauvais, Jennifer Berktold, Diane Boyd, Mary Butler, Karla Eisen, Martha Franklin, Rachel Gaddes, Carol Hagen, Wayne Hintze, Teresa Koenig, Chris Manglitz, Shelley Perry, Cynthia Robins, and Eden Segal

HEATHER YOUNG, George Washington University

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

REVIEWERS

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This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of this report:

Kathleen Brady, Medical University of South Carolina

Alicia L. Carriquiry, Iowa State University

Kenneth A. Dodge, Duke University Sanford School of Public Policy

Jason Hockenberry, Emory University Rollins School of Public Health

Kerry Knox, University of Rochester School of Medicine and Dentistry

Thomas Kosten, VA National Substance Use Disorders Program, Quality Enhancement Research Initiative (QUERI)

Captain (Retired) William P. Nash

Colonel (Retired) Elspeth Cameron Ritchie, Uniformed Services University of the Health Sciences, Washington D.C. Department of Mental Health

Jennifer J. Vasterling, VA Boston Healthcare System, Boston University School of Medicine

Colonel (Retired) Kelly A. Wolgast, Vanderbilt University School of Nursing

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by John C. Bailar III and Harold C. Sox, Dartmouth Medical School. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

PREFACE

image

In 2008, with the passage of the National Defense Authorization Act for fiscal year 2008 (PL 110-181), the National Academy of Sciences was asked to examine the readjustment needs of Operation Enduring Freedom and Operation Iraqi Freedom service members, their families, and affected communities. The Institute of Medicine assembled a committee to address the tasks in the legislation; the committee has worked for over 4 years to produce a preliminary report in 2010 and this final report. The legislation is broad and required the committee to look at many disparate issues.

As the committee considered the various issues, it became apparent that it would not be able to cover all of them in depth, inasmuch as each could fill a volume. The committee had to decide which issues to focus on and which to leave for future study. It used the legislation as its guide and focused on issues related to traumatic brain injuries, posttraumatic stress disorder, and other mental-health outcomes, although pain, polytrauma, burns, and amputations are also important.

The committee faced additional challenges as it approached its task. In its desire to address all aspects of its charge carefully, as required by the legislation, the committee initially tried to conduct original data analyses by linking various federal administrative datasets. There were, however, substantial organizational hurdles, and much additional time would have been required to obtain the data and conduct the analyses. The committee eventually abandoned that approach with some exceptions.

To say that this study is important understates the great needs of our military men and women and their families. As we traveled the country in Phase 1 of our study, we heard from active-duty personnel, veterans, and family members and we were humbled by the sacrifices made by all of them. As we continued to read the literature, we saw that much more study would be needed, but we recognized that military personnel, veterans, and family members need answers and help now.

We have all read the articles in the popular press, heard the radio broadcasts, and watched the news programs that highlight the troubling statistics regarding brain injuries, posttraumatic stress disorder, and other mental-health outcomes in our military personnel and veterans. We have read and heard about increasing marital stress, suicide, and substance abuse. We have read and heard about long wait times for appointments for treatment and disability examinations. Clearly, the nation, government agencies, communities, and families and friends need to respond. In many cases, there is a growing response, but more needs to be done to assist our active-duty military men and women, our National Guard and reserve members, our veterans, and their families. More coordination among programs is needed, more mental-health professionals are needed, and more treatments for wounds, seen and unseen, are needed. It is also necessary to reduce the stigma associated with mental illness and to reduce wait times for treatment. The Department of Defense and the Department of Veterans Affairs have made great progress in all those matters, but more will be needed—the issues will continue to plague our country for the indefinite future.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×

I deeply appreciate the work of my fellow committee members and their dedication and commitment to this project, which has been in progress for several years. We extend our appreciation to the many people who helped us along the way and to the numerous consultants whom we relied on for information and data analyses. We also thank the Institute of Medicine staff directed by Carolyn Fulco for their expert assistance, in particular Harriet Crawford for her patience and for generating numerous data files for our analyses, Laura Aiuppa for her work with the family and treatment groups, Renee Wlodarczyk for leading the access and barriers group, Marc Meisnere for his work with the community group, Cary Haver for her assistance with the economics group, Jonathan Schmelzer for his willingness to help out whenever needed, and Joe Goodman for his excellent attention to detail in getting us through 10 meetings. Finally, we thank Carolyn Fulco for her overall guidance and orchestration of the multiple pieces of the study.

The committee hopes that the findings in this report will result in improved outcomes for active-duty personnel, veterans, and their family members. We honor their commitment to the country, and it is for them that we persevered.


George W. Rutherford, MD, AM, Chair
Committee on the Assessment of Readjustment Needs of Military
Personnel, Veterans, and Their Families

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
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ABBREVIATIONS

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AF   Afghanistan
AFQT   Armed Forces Qualifying Test
BAI   Beck Anxiety Inventory
BDI   Beck Depression Inventory
BIRLS   Beneficiary Identification records Locator System
BMI   body mass index
BSI   Brief Symptom Inventory
CAPS   Clinician Administered PSTD Scale
CBO   Congressional Budget Office
CCEP   Comprehensive Clinical Evaluation Program
CDC   Centers for Disease Control and Prevention
CES   Combat Exposure Scale
CHCS   Composite Health Care System
CI   confidence interval
CIDI   Composite International Diagnostic Interview
CMI   chronic multisymptom illness
CNS   central nervous system
COD   cause of death
COSHPD   California Office of Statewide Health Planning and Development
CPG   Clinical Practice Guidelines
CVLT   California Verbal Learning Test
DCOE   Defense Centers of Excellence
DEERS   Defense Enrollment Eligibility Reporting System
DIBRS   Defense Incident-Based Reporting System
DMDC   Defense Manpower Data Center
DOD   Department of Defense
DSM   Diagnostic and Statistical Manual of Mental Disorders
DTAS   Defense Theater Accountability System
FY   fiscal year
GAO   Government Accountability Office
GWOT   Global War on Terror
ICD   International Statistical Classification of Diseases
IOM   Institute of Medicine
IZ   Iraq
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
×
MCS   Millennium Cohort Study
MDD   major depressive disorder
MDP   Medical SAS® Datasets
MDR   Military Health System Data Repository
mTBI   mild traumatic brain injury
N   number of study subjects
NAS   National Academy of Sciences
NCIC   National Crime Information Center
NDE   National Data Extract
NDI   National Death Index
NIH   National Institutes of Health
NIMH   National Institute of Mental Health
NPCD   National Patient Care Database
OED   Outpatient Encounter Database
OEF   Operation Enduring Freedom
OIF   Operation Iraqi Freedom
OND   Operation New Dawn
OR   odds ratio
PCL   Patient Checklist
PCL-C   Patient Checklist–Civilian
PCL-M   Patient Checklist–Military
PCS   permanent change of station
PDHA   Post-Deployment Health Assessment
PDHRA   Post-Deployment Health Re-Assessment
PHQ   Patient Health Questionnaire
PTF   Patient Treatment File
PTSD   posttraumatic stress disorder
SADR   Standard Ambulatory Data Record
SCID   Structured Clinical Interview for DSM-II-R
SF-12   12-Item Short Form Health Survey
SF-36   36-Item Short Form Health Survey
SIDR   Standard Inpatient Data Record
SMR   standardized mortality ratio
SSA   Social Security Administration
SUD   substance-use disorder
TBI   traumatic brain injury
VA   Department of Veterans Affairs
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
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VAMC   VA Medical Center
VBA   Veterans Benefits Administration
VETSNET   Veterans Service Network
VHA   Veterans Health Administration
VISN   Veterans Integrated Service Network
VSA   Veterans Service Area
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press. doi: 10.17226/13499.
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As of December 2012, Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in the deployment of about 2.2 million troops; there have been 2,222 US fatalities in OEF and Operation New Dawn (OND)1 and 4,422 in OIF. The numbers of wounded US troops exceed 16,000 in Afghanistan and 32,000 in Iraq. In addition to deaths and morbidity, the operations have unforeseen consequences that are yet to be fully understood.

In contrast with previous conflicts, the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments. Numerous reports in the popular press have made the public aware of issues that have pointed to the difficulty of military personnel in readjusting after returning from Iraq and Afghanistan. Many of those who have served in OEF and OIF readjust with few difficulties, but others have problems in readjusting to home, reconnecting with family members, finding employment, and returning to school.

In response to the return of large numbers of veterans from Iraq and Afghanistan with physical-health and mental-health problems and to the growing readjustment needs of active duty service members, veterans, and their family members, Congress included Section 1661 of the National Defense Authorization Act for fiscal year 2008. That section required the secretary of defense, in consultation with the secretary of veterans affairs, to enter into an agreement with the National Academies for a study of the physical-health, mental-health, and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF, their families, and their communities as a result of such deployment.

The study consisted of two phases. The Phase 1 task was to conduct a preliminary assessment. The Phase 2 task was to provide a comprehensive assessment of the physical, psychologic, social, and economic effects of deployment on and identification of gaps in care for members and former members, their families, and their communities. The Phase 1 report was completed in March 2010 and delivered to the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the relevant committees of the House of Representatives and the Senate. The secretaries of DOD and VA responded to the Phase 1 report in September 2010. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families fulfills the requirement for Phase 2.

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