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Norman SB, Luciano MT, Panza KE, Davis BC, Lyons M, Martis B, Matthews SC, Angkaw AC, Haller M, Lacefield K, Brody AL, Schnurr PP, Batki SL, Simpson TL, Anthenelli RM. A Randomized Clinical Trial of Prolonged Exposure Therapy With and Without Topiramate for Comorbid PTSD and Alcohol Use Disorder. Am J Psychiatry 2025; 182:452-462. [PMID: 40103353 DOI: 10.1176/appi.ajp.20240470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2025]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Prolonged exposure (PE) is an effective treatment for PTSD but shows smaller effects in patients with co-occurring AUD. Topiramate may help reduce alcohol use and PTSD symptoms. This double-blind, placebo-controlled outpatient clinical trial compared 12 sessions of PE plus either topiramate or placebo. METHODS One hundred U.S. veterans (mean age=45 years [SD=12], 84% men) with PTSD+AUD were randomly assigned to 16 weeks of treatment with PE+topiramate (up to 250 mg) or PE+placebo to examine effects on alcohol use and PTSD severity at posttreatment assessment and at 3- and 6-month follow-ups. RESULTS Percent heavy drinking days decreased significantly for both conditions but did not differ between groups. PTSD scores were lower in the PE+topiramate group than in the PE+placebo group at posttreatment assessment, but not at follow-ups. The same patterns were observed for loss of PTSD diagnosis and meaningful PTSD symptom change. Change in secondary outcomes (depression, quality of life) did not differ between conditions. CONCLUSIONS PE+topiramate was associated with a greater reduction in PTSD symptoms than PE+placebo during active treatment. The addition of topiramate led to more rapid and pronounced PTSD symptom reduction, which may be of benefit to patients. Because effects of topiramate were not maintained at longer-term follow-up, extending time on topiramate or additional strategies to prolong such effects may be useful. Topiramate did not show added benefit to PE for percent heavy drinking days or secondary outcomes.
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Affiliation(s)
- Sonya B Norman
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Matthew T Luciano
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Kaitlyn E Panza
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Brittany C Davis
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Michelle Lyons
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Brian Martis
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Scott C Matthews
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Abigail C Angkaw
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Moira Haller
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Katharine Lacefield
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Arthur L Brody
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Paula P Schnurr
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Steven L Batki
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Tracy L Simpson
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
| | - Robert M Anthenelli
- National Center for PTSD, Executive Division, White River Junction, VT (Norman, Schnurr); VA Center of Excellence for Stress and Mental Health, San Diego (Norman, Martis); University of California San Diego School of Medicine, La Jolla (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody, Anthenelli); VA San Diego Healthcare System, San Diego (Norman, Luciano, Panza, Lyons, Martis, Matthews, Angkaw, Haller, Lacefield, Brody); James A. Haley Veterans Hospital, Tampa, FL (Davis); Morsani College of Medicine, University of South Florida, Tampa (Davis); Geisel School of Medicine at Dartmouth College, Hanover, NH, (Schnurr); San Francisco Veterans Affairs Health Care System, San Francisco (Batki); Department of Psychiatry, University of California, San Francisco (Batki); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle (Simpson); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle (Simpson)
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Schnurr PP, Hamblen JL, Wolf J, Coller R, Collie C, Fuller MA, Holtzheimer PE, Kelly U, Lang AJ, McGraw K, Morganstein JC, Norman SB, Papke K, Petrakis I, Riggs D, Sall JA, Shiner B, Wiechers I, Kelber MS. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2024; 177:363-374. [PMID: 38408360 DOI: 10.7326/m23-2757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
DESCRIPTION The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
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Affiliation(s)
- Paula P Schnurr
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jessica L Hamblen
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jonathan Wolf
- Defense Health Agency, Falls Church, Virginia (J.W.)
| | - Rachael Coller
- Naval Medical Center San Diego, San Diego, California (R.C.)
| | - Claire Collie
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC (C.C.)
| | - Matthew A Fuller
- Veterans Health Administration Pharmacy Benefits Management Service and Case Western Reserve University School of Medicine, Cleveland, Ohio (M.A.F.)
| | - Paul E Holtzheimer
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Ursula Kelly
- Joseph Maxwell Cleland Atlanta VA Medical Center and Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia (U.K.)
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health at VA San Diego Healthcare System and University of California, San Diego, San Diego, California (A.J.L.)
| | - Kate McGraw
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
| | - Joshua C Morganstein
- Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress, Bethesda, Maryland (J.C.M.)
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, and University of California, San Diego, San Diego, California (S.B.N.)
| | - Katie Papke
- National Social Work Program Office, Veterans Health Administration, Washington, DC (K.P.)
| | - Ismene Petrakis
- National Center for PTSD, West Haven, and Yale University School of Medicine, New Haven, Connecticut (I.P.)
| | - David Riggs
- Uniformed Services University of the Health Sciences, Center for Deployment Psychology, Bethesda, Maryland (D.R.)
| | - James A Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.A.S.)
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (B.S.)
| | - Ilse Wiechers
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC; Yale University School of Medicine, New Haven, Connecticut; and University of California, San Francisco, School of Medicine, San Francisco, California (I.W.)
| | - Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
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