SSRI Withdrawal Can Induce Psychosis, Mania

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Note: Sertraline = Zoloft

http://www.cpa-apc.org/publications/archives/cjp/2002/august/letterspsychoticman\

ia.asp

Psychotic Mania in Bipolar II Depression Related to Sertraline

Discontinuation

Canadian Journal of Psychiatry, August 2002

Letters to the Editor

Dear Editor:

Discontinuing selective serotonin reuptake inhibitors (SSRIs) may induce a

syndrome wherein the main neuropsychiatric symptoms are dizziness,

shock-like sensations, anxiety, irritability, agitation, and insomnia. These

symptoms usually develop 1 to 7 days after either abrupt or gradual

discontinuation (1-3). Antidepressant discontinuation may also induce mania,

mainly reported with tricyclics and monoamine oxidase inhibitors (MAOIs) but

also observed with SSRIs (4). Acute psychosis has been reported in

previously nonpsychotic patients following abrupt discontinuation of the

MAOI phenelzine (5). Biological mechanisms may be cholinergic overdrive

activating monoaminenergic systems (6) or a hyposerotonergic state arising

from SSRI-induced postsynaptic serotonin receptor desensitization coupled

with increased serotonin reuptake after discontinuation (7).

I report the case of a patient diagnosed with bipolar disorder II (BD II,

depression and hypomania alternating) according to DSM-IV criteria. This

patient had a first episode of psychotic mania soon after rapid

discontinuation of sertraline. A Medline search did not find similar

reports, although 2 similar cases were reported in a case series (4).

Case Report

A 32-year-old woman with long-term BD II had been treated during the last 2

years with sertraline 50 mg daily for depression, which had partially

remitted. She was taking no other drugs, and her family doctor tried

discontinuing sertraline. The patient took 25 mg daily for 1 week and then

discontinued sertraline altogether. After some days, she felt anxiety,

irritability, agitation, insomnia, and " electrical shocks " all over her

body. A few days later, she became manic, showing marked irritability,

insomnia, talkativeness, racing thoughts, psychomotor agitation, increased

goal-directed activities, and marked impairment of functioning. Because she

could not understand the cause of the very distressing " electrical shocks, "

she became convinced that family members were inducing the shocks to kill

her. The clinical picture worsened in 2 weeks, when she ran away from home

for fear of being killed. At this point, she was involuntarily committed to

hospital. After 2 weeks of treatment with a neuroleptic, her delusions and

mania disappeared, and she became mildly depressed. In the following weeks,

after the neuroleptic dosage was gradually reduced, her mood became normal.

My own long-term research on BD II supports her diagnosis. Because she had

never had mania, a spontaneous cycling concurrent with sertraline

discontinuation seems unlikely. However, switching from BD II to BD I during

long-term follow-up has been reported in a small percentage of patients (8).

Mania-related confounding elements could be antidepressant-induced mania,

agitated depression, and SSRI discontinuation syndrome (4).

Antidepressant-induced mania usually appears 3 to 6 weeks after

antidepressant institution (9) and seems unlikely in this case because this

patient had been taking sertraline for 2 years. Agitated depression also

seems unlikely: she was agitated and manic. The timing of the symptoms

suggests a link with sertraline discontinuation. However, while she showed

some typical symptoms of SSRI discontinuation syndrome, psychotic mania is

not listed among them (1,2). It seems that the psychotic mania presented by

this patient may be related to mania induced by antidepressant

discontinuation. This case presents a link between such mania and SSRI

discontinuation syndrome. The link is the shock-like sensations, which she

believed were induced by family members to kill her. The mechanism

underlying this psychotic mania after sertraline discontinuation may be a

hyposerotonergic state (7). The serotonin system is closely linked with the

dopamine system: increased serotonin reduces dopamine activity, and reduced

serotonin increases dopamine activity (10). Because increased dopamine has

historically been linked to psychosis and mania (11), discontinuing

sertraline may have increased dopamine activity too greatly. The bipolar

vulnerability of this patient may have heightened her sensitivity to this

effect. It seems likely that, owing to sertraline's weak dopamine reuptake

blockade, these biochemical effects overcame sertraline's possible

downregulating effect on dopamine receptors (12).

References

1. Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake

inhibitor discontinuation syndrome: proposed diagnostic criteria. J

Psychiatry Neurosci 2000;25:255-61.

2. Michelson D, Fava M, Amsterdam J, Apter J, Londborg P, Tamura R, and

others. Interruption of selective serotonin reuptake inhibitor treatment.

Double-blind, placebo-controlled trial. Br J Psychiatry 2000;176:363-8.

3. Benazzi F. Sertraline discontinuation syndrome presenting with severe

depression and compulsions. Biol Psychiatry 1998;43:929-30.

4. Goldstein TR, Frye MA, Denicoff KD, - E, Leverich GS,

AL, and others. Antidepressant discontinuation-related mania: critical

prospective observation and theoretical implications in bipolar disorder. J

Clin Psychiatry 1999;60:563-7.

5. Liskin B, Roose SP, Walsh BT, WK. Acute psychosis following

phenelzine discontinuation. J Clin Psychopharmacol 1985;5:46-7.

6. Dilsaver SC, Greden JF. Antidepressant withdrawal-induced activation

(hypomania and mania): mechanism and theoretical significance. Brain Res Rev

1984;7:29-48.

7. Zajecka J, KA, S. Discontinuation symptoms after treatment

with serotonin reuptake inhibitors: a literature review. J Clin Psychiatry

1997;58:291-7.

8. Coryell W, Endicott J, Maser JD, Keller MB, Leon AC, Akiskal HS. Long-

term stability of polarity distinctions in the affective disorders. Am J

Psychiatry 1995;152:385-90.

9. Wehr T, Goodwin F. Can antidepressants cause mania and worsen the course

of affective illness? Am J Psychiatry 1987;144:1403-11.

10. Kapur S, Remington G. Serotonin-dopamine interaction and its relevance

to schizophrenia. Am J Psychiatry 1996;153:466-76.

11. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford

University Press; 1990.

12. Richelson E. Synaptic effects of antidepressants. J Clin Psychopharmacol

1996;16 (Suppl 2):1S-9S.

Franco Benazzi

Forlí, Italy

_________________________________________________________________

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[Guest guest]

Note: Sertraline = Zoloft

http://www.cpa-apc.org/publications/archives/cjp/2002/august/letterspsychoticman\

ia.asp

Psychotic Mania in Bipolar II Depression Related to Sertraline

Discontinuation

Canadian Journal of Psychiatry, August 2002

Letters to the Editor

Dear Editor:

Discontinuing selective serotonin reuptake inhibitors (SSRIs) may induce a

syndrome wherein the main neuropsychiatric symptoms are dizziness,

shock-like sensations, anxiety, irritability, agitation, and insomnia. These

symptoms usually develop 1 to 7 days after either abrupt or gradual

discontinuation (1-3). Antidepressant discontinuation may also induce mania,

mainly reported with tricyclics and monoamine oxidase inhibitors (MAOIs) but

also observed with SSRIs (4). Acute psychosis has been reported in

previously nonpsychotic patients following abrupt discontinuation of the

MAOI phenelzine (5). Biological mechanisms may be cholinergic overdrive

activating monoaminenergic systems (6) or a hyposerotonergic state arising

from SSRI-induced postsynaptic serotonin receptor desensitization coupled

with increased serotonin reuptake after discontinuation (7).

I report the case of a patient diagnosed with bipolar disorder II (BD II,

depression and hypomania alternating) according to DSM-IV criteria. This

patient had a first episode of psychotic mania soon after rapid

discontinuation of sertraline. A Medline search did not find similar

reports, although 2 similar cases were reported in a case series (4).

Case Report

A 32-year-old woman with long-term BD II had been treated during the last 2

years with sertraline 50 mg daily for depression, which had partially

remitted. She was taking no other drugs, and her family doctor tried

discontinuing sertraline. The patient took 25 mg daily for 1 week and then

discontinued sertraline altogether. After some days, she felt anxiety,

irritability, agitation, insomnia, and " electrical shocks " all over her

body. A few days later, she became manic, showing marked irritability,

insomnia, talkativeness, racing thoughts, psychomotor agitation, increased

goal-directed activities, and marked impairment of functioning. Because she

could not understand the cause of the very distressing " electrical shocks, "

she became convinced that family members were inducing the shocks to kill

her. The clinical picture worsened in 2 weeks, when she ran away from home

for fear of being killed. At this point, she was involuntarily committed to

hospital. After 2 weeks of treatment with a neuroleptic, her delusions and

mania disappeared, and she became mildly depressed. In the following weeks,

after the neuroleptic dosage was gradually reduced, her mood became normal.

My own long-term research on BD II supports her diagnosis. Because she had

never had mania, a spontaneous cycling concurrent with sertraline

discontinuation seems unlikely. However, switching from BD II to BD I during

long-term follow-up has been reported in a small percentage of patients (8).

Mania-related confounding elements could be antidepressant-induced mania,

agitated depression, and SSRI discontinuation syndrome (4).

Antidepressant-induced mania usually appears 3 to 6 weeks after

antidepressant institution (9) and seems unlikely in this case because this

patient had been taking sertraline for 2 years. Agitated depression also

seems unlikely: she was agitated and manic. The timing of the symptoms

suggests a link with sertraline discontinuation. However, while she showed

some typical symptoms of SSRI discontinuation syndrome, psychotic mania is

not listed among them (1,2). It seems that the psychotic mania presented by

this patient may be related to mania induced by antidepressant

discontinuation. This case presents a link between such mania and SSRI

discontinuation syndrome. The link is the shock-like sensations, which she

believed were induced by family members to kill her. The mechanism

underlying this psychotic mania after sertraline discontinuation may be a

hyposerotonergic state (7). The serotonin system is closely linked with the

dopamine system: increased serotonin reduces dopamine activity, and reduced

serotonin increases dopamine activity (10). Because increased dopamine has

historically been linked to psychosis and mania (11), discontinuing

sertraline may have increased dopamine activity too greatly. The bipolar

vulnerability of this patient may have heightened her sensitivity to this

effect. It seems likely that, owing to sertraline's weak dopamine reuptake

blockade, these biochemical effects overcame sertraline's possible

downregulating effect on dopamine receptors (12).

References

1. Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake

inhibitor discontinuation syndrome: proposed diagnostic criteria. J

Psychiatry Neurosci 2000;25:255-61.

2. Michelson D, Fava M, Amsterdam J, Apter J, Londborg P, Tamura R, and

others. Interruption of selective serotonin reuptake inhibitor treatment.

Double-blind, placebo-controlled trial. Br J Psychiatry 2000;176:363-8.

3. Benazzi F. Sertraline discontinuation syndrome presenting with severe

depression and compulsions. Biol Psychiatry 1998;43:929-30.

4. Goldstein TR, Frye MA, Denicoff KD, - E, Leverich GS,

AL, and others. Antidepressant discontinuation-related mania: critical

prospective observation and theoretical implications in bipolar disorder. J

Clin Psychiatry 1999;60:563-7.

5. Liskin B, Roose SP, Walsh BT, WK. Acute psychosis following

phenelzine discontinuation. J Clin Psychopharmacol 1985;5:46-7.

6. Dilsaver SC, Greden JF. Antidepressant withdrawal-induced activation

(hypomania and mania): mechanism and theoretical significance. Brain Res Rev

1984;7:29-48.

7. Zajecka J, KA, S. Discontinuation symptoms after treatment

with serotonin reuptake inhibitors: a literature review. J Clin Psychiatry

1997;58:291-7.

8. Coryell W, Endicott J, Maser JD, Keller MB, Leon AC, Akiskal HS. Long-

term stability of polarity distinctions in the affective disorders. Am J

Psychiatry 1995;152:385-90.

9. Wehr T, Goodwin F. Can antidepressants cause mania and worsen the course

of affective illness? Am J Psychiatry 1987;144:1403-11.

10. Kapur S, Remington G. Serotonin-dopamine interaction and its relevance

to schizophrenia. Am J Psychiatry 1996;153:466-76.

11. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford

University Press; 1990.

12. Richelson E. Synaptic effects of antidepressants. J Clin Psychopharmacol

1996;16 (Suppl 2):1S-9S.

Franco Benazzi

Forlí, Italy

_________________________________________________________________

The new MSN 8: smart spam protection and 2 months FREE*

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[Guest guest]

Note: Sertraline = Zoloft

http://www.cpa-apc.org/publications/archives/cjp/2002/august/letterspsychoticman\

ia.asp

Psychotic Mania in Bipolar II Depression Related to Sertraline

Discontinuation

Canadian Journal of Psychiatry, August 2002

Letters to the Editor

Dear Editor:

Discontinuing selective serotonin reuptake inhibitors (SSRIs) may induce a

syndrome wherein the main neuropsychiatric symptoms are dizziness,

shock-like sensations, anxiety, irritability, agitation, and insomnia. These

symptoms usually develop 1 to 7 days after either abrupt or gradual

discontinuation (1-3). Antidepressant discontinuation may also induce mania,

mainly reported with tricyclics and monoamine oxidase inhibitors (MAOIs) but

also observed with SSRIs (4). Acute psychosis has been reported in

previously nonpsychotic patients following abrupt discontinuation of the

MAOI phenelzine (5). Biological mechanisms may be cholinergic overdrive

activating monoaminenergic systems (6) or a hyposerotonergic state arising

from SSRI-induced postsynaptic serotonin receptor desensitization coupled

with increased serotonin reuptake after discontinuation (7).

I report the case of a patient diagnosed with bipolar disorder II (BD II,

depression and hypomania alternating) according to DSM-IV criteria. This

patient had a first episode of psychotic mania soon after rapid

discontinuation of sertraline. A Medline search did not find similar

reports, although 2 similar cases were reported in a case series (4).

Case Report

A 32-year-old woman with long-term BD II had been treated during the last 2

years with sertraline 50 mg daily for depression, which had partially

remitted. She was taking no other drugs, and her family doctor tried

discontinuing sertraline. The patient took 25 mg daily for 1 week and then

discontinued sertraline altogether. After some days, she felt anxiety,

irritability, agitation, insomnia, and " electrical shocks " all over her

body. A few days later, she became manic, showing marked irritability,

insomnia, talkativeness, racing thoughts, psychomotor agitation, increased

goal-directed activities, and marked impairment of functioning. Because she

could not understand the cause of the very distressing " electrical shocks, "

she became convinced that family members were inducing the shocks to kill

her. The clinical picture worsened in 2 weeks, when she ran away from home

for fear of being killed. At this point, she was involuntarily committed to

hospital. After 2 weeks of treatment with a neuroleptic, her delusions and

mania disappeared, and she became mildly depressed. In the following weeks,

after the neuroleptic dosage was gradually reduced, her mood became normal.

My own long-term research on BD II supports her diagnosis. Because she had

never had mania, a spontaneous cycling concurrent with sertraline

discontinuation seems unlikely. However, switching from BD II to BD I during

long-term follow-up has been reported in a small percentage of patients (8).

Mania-related confounding elements could be antidepressant-induced mania,

agitated depression, and SSRI discontinuation syndrome (4).

Antidepressant-induced mania usually appears 3 to 6 weeks after

antidepressant institution (9) and seems unlikely in this case because this

patient had been taking sertraline for 2 years. Agitated depression also

seems unlikely: she was agitated and manic. The timing of the symptoms

suggests a link with sertraline discontinuation. However, while she showed

some typical symptoms of SSRI discontinuation syndrome, psychotic mania is

not listed among them (1,2). It seems that the psychotic mania presented by

this patient may be related to mania induced by antidepressant

discontinuation. This case presents a link between such mania and SSRI

discontinuation syndrome. The link is the shock-like sensations, which she

believed were induced by family members to kill her. The mechanism

underlying this psychotic mania after sertraline discontinuation may be a

hyposerotonergic state (7). The serotonin system is closely linked with the

dopamine system: increased serotonin reduces dopamine activity, and reduced

serotonin increases dopamine activity (10). Because increased dopamine has

historically been linked to psychosis and mania (11), discontinuing

sertraline may have increased dopamine activity too greatly. The bipolar

vulnerability of this patient may have heightened her sensitivity to this

effect. It seems likely that, owing to sertraline's weak dopamine reuptake

blockade, these biochemical effects overcame sertraline's possible

downregulating effect on dopamine receptors (12).

References

1. Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake

inhibitor discontinuation syndrome: proposed diagnostic criteria. J

Psychiatry Neurosci 2000;25:255-61.

2. Michelson D, Fava M, Amsterdam J, Apter J, Londborg P, Tamura R, and

others. Interruption of selective serotonin reuptake inhibitor treatment.

Double-blind, placebo-controlled trial. Br J Psychiatry 2000;176:363-8.

3. Benazzi F. Sertraline discontinuation syndrome presenting with severe

depression and compulsions. Biol Psychiatry 1998;43:929-30.

4. Goldstein TR, Frye MA, Denicoff KD, - E, Leverich GS,

AL, and others. Antidepressant discontinuation-related mania: critical

prospective observation and theoretical implications in bipolar disorder. J

Clin Psychiatry 1999;60:563-7.

5. Liskin B, Roose SP, Walsh BT, WK. Acute psychosis following

phenelzine discontinuation. J Clin Psychopharmacol 1985;5:46-7.

6. Dilsaver SC, Greden JF. Antidepressant withdrawal-induced activation

(hypomania and mania): mechanism and theoretical significance. Brain Res Rev

1984;7:29-48.

7. Zajecka J, KA, S. Discontinuation symptoms after treatment

with serotonin reuptake inhibitors: a literature review. J Clin Psychiatry

1997;58:291-7.

8. Coryell W, Endicott J, Maser JD, Keller MB, Leon AC, Akiskal HS. Long-

term stability of polarity distinctions in the affective disorders. Am J

Psychiatry 1995;152:385-90.

9. Wehr T, Goodwin F. Can antidepressants cause mania and worsen the course

of affective illness? Am J Psychiatry 1987;144:1403-11.

10. Kapur S, Remington G. Serotonin-dopamine interaction and its relevance

to schizophrenia. Am J Psychiatry 1996;153:466-76.

11. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford

University Press; 1990.

12. Richelson E. Synaptic effects of antidepressants. J Clin Psychopharmacol

1996;16 (Suppl 2):1S-9S.

Franco Benazzi

Forlí, Italy

_________________________________________________________________

The new MSN 8: smart spam protection and 2 months FREE*

http://join.msn.com/?page=features/junkmail

[Guest guest]

Note: Sertraline = Zoloft

http://www.cpa-apc.org/publications/archives/cjp/2002/august/letterspsychoticman\

ia.asp

Psychotic Mania in Bipolar II Depression Related to Sertraline

Discontinuation

Canadian Journal of Psychiatry, August 2002

Letters to the Editor

Dear Editor:

Discontinuing selective serotonin reuptake inhibitors (SSRIs) may induce a

syndrome wherein the main neuropsychiatric symptoms are dizziness,

shock-like sensations, anxiety, irritability, agitation, and insomnia. These

symptoms usually develop 1 to 7 days after either abrupt or gradual

discontinuation (1-3). Antidepressant discontinuation may also induce mania,

mainly reported with tricyclics and monoamine oxidase inhibitors (MAOIs) but

also observed with SSRIs (4). Acute psychosis has been reported in

previously nonpsychotic patients following abrupt discontinuation of the

MAOI phenelzine (5). Biological mechanisms may be cholinergic overdrive

activating monoaminenergic systems (6) or a hyposerotonergic state arising

from SSRI-induced postsynaptic serotonin receptor desensitization coupled

with increased serotonin reuptake after discontinuation (7).

I report the case of a patient diagnosed with bipolar disorder II (BD II,

depression and hypomania alternating) according to DSM-IV criteria. This

patient had a first episode of psychotic mania soon after rapid

discontinuation of sertraline. A Medline search did not find similar

reports, although 2 similar cases were reported in a case series (4).

Case Report

A 32-year-old woman with long-term BD II had been treated during the last 2

years with sertraline 50 mg daily for depression, which had partially

remitted. She was taking no other drugs, and her family doctor tried

discontinuing sertraline. The patient took 25 mg daily for 1 week and then

discontinued sertraline altogether. After some days, she felt anxiety,

irritability, agitation, insomnia, and " electrical shocks " all over her

body. A few days later, she became manic, showing marked irritability,

insomnia, talkativeness, racing thoughts, psychomotor agitation, increased

goal-directed activities, and marked impairment of functioning. Because she

could not understand the cause of the very distressing " electrical shocks, "

she became convinced that family members were inducing the shocks to kill

her. The clinical picture worsened in 2 weeks, when she ran away from home

for fear of being killed. At this point, she was involuntarily committed to

hospital. After 2 weeks of treatment with a neuroleptic, her delusions and

mania disappeared, and she became mildly depressed. In the following weeks,

after the neuroleptic dosage was gradually reduced, her mood became normal.

My own long-term research on BD II supports her diagnosis. Because she had

never had mania, a spontaneous cycling concurrent with sertraline

discontinuation seems unlikely. However, switching from BD II to BD I during

long-term follow-up has been reported in a small percentage of patients (8).

Mania-related confounding elements could be antidepressant-induced mania,

agitated depression, and SSRI discontinuation syndrome (4).

Antidepressant-induced mania usually appears 3 to 6 weeks after

antidepressant institution (9) and seems unlikely in this case because this

patient had been taking sertraline for 2 years. Agitated depression also

seems unlikely: she was agitated and manic. The timing of the symptoms

suggests a link with sertraline discontinuation. However, while she showed

some typical symptoms of SSRI discontinuation syndrome, psychotic mania is

not listed among them (1,2). It seems that the psychotic mania presented by

this patient may be related to mania induced by antidepressant

discontinuation. This case presents a link between such mania and SSRI

discontinuation syndrome. The link is the shock-like sensations, which she

believed were induced by family members to kill her. The mechanism

underlying this psychotic mania after sertraline discontinuation may be a

hyposerotonergic state (7). The serotonin system is closely linked with the

dopamine system: increased serotonin reduces dopamine activity, and reduced

serotonin increases dopamine activity (10). Because increased dopamine has

historically been linked to psychosis and mania (11), discontinuing

sertraline may have increased dopamine activity too greatly. The bipolar

vulnerability of this patient may have heightened her sensitivity to this

effect. It seems likely that, owing to sertraline's weak dopamine reuptake

blockade, these biochemical effects overcame sertraline's possible

downregulating effect on dopamine receptors (12).

References

1. Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake

inhibitor discontinuation syndrome: proposed diagnostic criteria. J

Psychiatry Neurosci 2000;25:255-61.

2. Michelson D, Fava M, Amsterdam J, Apter J, Londborg P, Tamura R, and

others. Interruption of selective serotonin reuptake inhibitor treatment.

Double-blind, placebo-controlled trial. Br J Psychiatry 2000;176:363-8.

3. Benazzi F. Sertraline discontinuation syndrome presenting with severe

depression and compulsions. Biol Psychiatry 1998;43:929-30.

4. Goldstein TR, Frye MA, Denicoff KD, - E, Leverich GS,

AL, and others. Antidepressant discontinuation-related mania: critical

prospective observation and theoretical implications in bipolar disorder. J

Clin Psychiatry 1999;60:563-7.

5. Liskin B, Roose SP, Walsh BT, WK. Acute psychosis following

phenelzine discontinuation. J Clin Psychopharmacol 1985;5:46-7.

6. Dilsaver SC, Greden JF. Antidepressant withdrawal-induced activation

(hypomania and mania): mechanism and theoretical significance. Brain Res Rev

1984;7:29-48.

7. Zajecka J, KA, S. Discontinuation symptoms after treatment

with serotonin reuptake inhibitors: a literature review. J Clin Psychiatry

1997;58:291-7.

8. Coryell W, Endicott J, Maser JD, Keller MB, Leon AC, Akiskal HS. Long-

term stability of polarity distinctions in the affective disorders. Am J

Psychiatry 1995;152:385-90.

9. Wehr T, Goodwin F. Can antidepressants cause mania and worsen the course

of affective illness? Am J Psychiatry 1987;144:1403-11.

10. Kapur S, Remington G. Serotonin-dopamine interaction and its relevance

to schizophrenia. Am J Psychiatry 1996;153:466-76.

11. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford

University Press; 1990.

12. Richelson E. Synaptic effects of antidepressants. J Clin Psychopharmacol

1996;16 (Suppl 2):1S-9S.

Franco Benazzi

Forlí, Italy

_________________________________________________________________

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