1

Original Article

Reasons for Living and Suicide Attempt in Major Depression

Vikas Malik

Rachana Pole

G.K.Vankar

Abstract

Background: There are known risk factors for suicide in major depression but there is lack

of knowledge about what protects people against suicide.

Aims: To find out Reasons of living in Major Depression and to compare patents with and

without suicidal ideas as regards Reasons for living, demographic and disease related

characteristics, severity of depression and number of stressful life events.

Material and Methods: Patients with Major Depression attending medical college

psychiatry OPD were screened for past suicide attempt. All patients were evaluated for

severity of depression(both subjective and objective), severity of suicidal ideas, hopelessness,

reasonds for living and stressful life events. Suicide attempter and non-attempters were

compared regarding these parameters.

Results: Those who had attempted suicide had more severe depression and higher suicidal

ideas, and lower reasons for living inventory scores, though the stressful life events were

not in excess.In On two subscales of reasons for living inventory, those who attempted

suicide had significantly higher scores- Survival and coping belief as well as fear of suicide.

Conclusions: Clinicians should routinely interview patients regarding suicide risk factors as

well as the reasons for living; the later has potential to be protective against suicide.

(Keywords: major depression, suicide, reasons for living)

2

Introduction

Various biopsychosocial factors predispose a person to suicide , however there is paucity of

research on what factors protect a person with major depressive disorder against suicide.

Despite of intense psychological pain, many patients want to live. During interviews,

patients many a time narrate their reasons for living, mainly socio-cultural in nature. This is a

first systematic study exploring reasons for living in Indian patients suffering from major

depressive disorder.

Over two decades of research have suggested a positive association between stressful life

events and subsequent.1-4 Loss or “exit” events (such as marital separation o death), which

may have particularly strong effects on self esteem, occur more frequently among depressed

than among non-depressed persons. 5 Depressed patients have higher mean life event score

as compared to non-depressed subjects. 5-9

In terms of type of life events, it is seen that depressed patients experience significantly

higher proportion of life events related to death of a family member, personal health related

events, bereavement, interpersonal and social events. 10 Studies in elderly also suggest that

life events, especially financial problems and death in the family are as important a

precipitating event for depression as they are in young adult. 11

Studies have also reported

that economic and interpersonal relationship difficulties, partner violence, sexual coercion by

the partner as the common causal factors related to development of depression in general and

depression during antenatal and postnatal period. It has been shown that gender of the

newborn child is an important determinant of postnatal depression.12

Bagadia et al. attempted to examine the relationship between unemployment and suicide and

concluded that though unemployment may be an important factor in suicide it did not appear

to be the causative factor.13

Srivatsava et al.(2004) identified unemployment, presence of a

stressful life event in the last six months, suffering from physical disorders and having

idiopathic pain as definite risk factors for attempting suicide.14

In a study on 100 female

hospitalzed burns patients, Venkoba Rao, et al. reported that the most common reasons for

suicidal attempts were marital and interpersonal problems followed by psychiatric and

physical illnesses respectively.15 Sethi, et al. studied patients admitted for self destructive behavior and found that

Financial stress, rejection in love and strained familial relationships were the most common

causes. 16 Das, et al.

n their study on subjects with intentional self harm attempts The most

common reasons for the attempt were interpersonal problems with family members and

spouse.17

3

Linehan et al. (1983) suggested that reasons for not taking one’s life despite suicidal

thoughts or considerations is imortant aspect of evaluation. A major assumption of these

reasons for living instruments is that suicidal individuals are lacking in adaptive beliefs

present among nonsuicidal individuals that deter suicidal behavior. The reasons for living

examined through these instruments can be considered buffers or personal and environmental

contingencies operating against suicide. 18 In their original research, Linehan and colleagues

(1983) found that individuals with prior suicidal behavior reported fewer reasons for living

than individuals with no suicidal history. Moreover, those with suicidal histories valued

reasons for living to a smaller degree. That is, they rated reasons for living as less important

than individuals with no suicidal history.18

Reasons for living instruments have been

developed for a diverse groups and research has offered further support for the assessment

of reasons for living in diverse populations (e.g., psychiatric inpatients, college students,

delinquent adolescents) (Cole, 1989; Gutierrez et al., 2002; Osman et al., 1993, 1998).19-21

Table 1 shows some selected studies on Reasons for Living

Researchers Conclusions

Segal And

Needham(2007) 22

Robust gender differences on the RFL found among younger individuals appear to

diminish with advancing age, although it is unclear to what extent older men improve in

the reasons for staying alive or older women decline in their reasons for staying alive.

Connel and

Meyer (1991)23

A significant difference existed between suicidal and nonsuicidal individuals on the RFL.

Mclaren

S.(2011)24

The influence of age, gender, or the combination of the two varies according to the reason

for living being investigated. Being female was associated with higher total, child-related

concerns and fear of suicide (FS) scores, whereas increasing age was associated with

higher total, responsibility to family (RF), FS, and moral objections scores.

Segal et al(2012)25

No individual PD features or personality traits contributed significant variance

in reasons for living.

Devic et al

(2011)26

In bipolar depression patients Higher score on the moral or religious objections to

suicide subscale of the RFLI is associated with fewer suicidal acts in depressed bipolar

patients. Patients with religious affiliation had comparatively higher scores on the moral

or religious objections to suicide subscale of the RFLI

Oquendo et al

(2005) 27

explored protective factors against suicidal behavior in Latinos.. Latinos reported

significantly less suicidal ideation and made less lethal attempts. On the RFLI, Latinos

scored significantly higher on subscales regarding survival and coping beliefs,

responsibility to family, and moral objections to suicide, possibly reflective of cultural

norms endorsed by Latino groups.

Choi and

Rogers(2010)28

Validity of the CSRLI subscales was supported through significant negative relations with

measures of depression and hopelessness

June et al.(2009)29

high religiousness was associated with more reasons for living. Ethnicity alone did not

meaningfully account for variance differences in reasons for living, but significant

interactions indicated that the relationship between religiousness

and reasons for living was stronger for African Americans

4

Edelstein(2009) 30

Negative associations among RFL-OA scores and measures of depression and suicide

ideation. RFL-OA scores predicted current and worst-episode suicide ideation above and

beyond current depression

Pinto et al(1998)31

RFL factors were associated with suicidal ideation, depression, and hopelessness, and

predicted unique variance in suicidal ideation over that accounted for by depression and

hopelessness.

Ellis and Smith

(1991)32

Positive correlations were found between religious well-being and the total RFL score and

Moral Objections subscale and between existential well-being and several RFL scales.

Range and

Stringer(1996) 33

Reasons for living and coping abilities among older adults. Overall coping was

significantly positively correlated with total reasons for living

Connel and

meyer(1991) 34

Adolescents: A significant difference existed between suicidal and nonsuicidal individuals

on the RFL. Hopelessness and depression were found to be correlated significantly with

suicidal behavior; social desirability was found to be high among those who were not

suicidal and declined as suicidal behaviors became more severe.

Malone et

al(2000)35

Neither objective severity of depression nor quantity of recent life events differed between

the two groups.

During a depressive episode, the subjective perception of stressful life events may be

more germane to suicidal expression than the objective quantity of such events .

Richardson-

Vejlgaard et

al(2009)36

Mood disorder patients with or without AUD. RFL scores were no different between

groups, except in one respect: patients with AUD had fewer moral objections to suicide.

Higher suicidal ideation was associated with lower MOS scores. Prior suicidal behavior

was associated with lower MOS, and higher current suicidal ideation.

Aims and Objectives

To find out the protective factors against suicidal acts in patients suffering from major

depression

To study the demographic variables and clinical features in patients with major

depression with or without suicide attempt.

Materials and Method

Patients visiting psychiatric OPD at Shree Sayaji General Hospital (SSGH) which is a

medical college affiliated tertiary care general hospital in Vadodara, Gujarat

Patients who met DSM-IV-TR criteria for Major depressive disorder 37

, Patients with

psychotic features like delusions, hallucinations, grossly disorganized behavior and

disorganized speech (irrelevancy, incoherence, loosening of association etc.), With mental

retardation , With delirium due to any cause ,With dementia and other cognitive disorders

and With altered sensorium were excluded.

Methodology

5

Subjects, aged 18-80 years, who met DSM-IV-TR criteria for current major depressive

episode, were recruited from patients coming to Psychiatry OPD of S.S.G.

Hospital,Vadodara Subjects were free of severe, unstable medical and neurologic disorders.

The subjects were clinically assessed for depression and the diagnosis of a current major

depressive episode was based on DSM-IV-TR . The severity of the major depressive episode was measured objectively with the Hamilton

Depression Rating Scale 38

and subjectively with the Beck Depression Inventory .39

General

Psychopathology was assessed by using the Brief Psychiatric Rating Scale.40

In addition to

administrating the Reasons for Living Inventory, 41

the quantity and severity of life events

was assessed by using the Presumptive Stressful Life Event Scale .42

The Scale for Suicidal

Ideation was administered to assess current suicidal ideation.43

6

Flow chart for the study

Instruments Used In the Study

Hamilton Rating Scale For Depression (Hamilton,1960)38

The Hamilton Rating Scale for Depression (HAM-D, HRSD) is the most widely utilized

rating scale to assess symptoms of depression. The HAM-D is an observer-rated scale

consisting of 21 items. Ratings are made on the basis of the clinical interview. The items are

rated on either a 0 to 4 spectrum (0 = none/absent and 4 = most severe) or a 0 to 2 spectrum

(0 = absent/none and 2 = severe). HAM-D is used to assess the severity of depression.

Beck Depression Inventory (Abridged Version)(Beck,1961)39

The Beck Depression Inventory (BDI), is a rating to measure the severity for depression.

Unlike HAM-D, the BDI is a self rated scale, in which individuals rate their own symptoms

for depression. For the present study a 13 item Gujarati Version was used (Vankar, 1994).

The individuals are asked to rate themselves on a 0 to 3 spectrum (0 = least, 3 = most).

Brief Psychiatric Rating Scale(Overall and Graham,1962) 40

The Brief Psychiatric Rating Scale (BPRS) is a relatively brief scale that measures major

psychotic and non-psychotic symptoms in individuals with a major psychiatric disorder. It’s a

clinician rated 18-item scale. The rating is based upon observations made by the

clinician/rater during 15 to 30 minute interview and subject verbal report.

Reasons for Living Inventory (Linehan et al. 1983 ) 41

The Reasons for Living Inventory is a self report instrument that measures beliefs that may

contribute to the inhibition of suicidal behavior. It is composed of six factors: Survival and

Coping Beliefs, Responsibility to Family, Child Related Concerns, Fear of Suicide, Fear of

Social Disapproval, and Moral Objections to Suicide. The scale consists of 48 statements

which are rated by the individuals on a 1 to 6 spectrum (1=Not at all Important and 6=

Extremely Important).

1. Survival and coping beliefs

Psychiatry OPD

Patients meeting criteria for DSM IV

TRN=70

BDI

HDRS

SIS Scale

BPRS

PSLE

Reasons for Living Inventory

Suicide

Attempers=24

Suicide non-

attempters=46

7

Survival and Coping reasons for living combine a number of beliefs about life and living.

Included are reason having to do with positive expectations about the future and coping

abilities of an individual. The former set of beliefs seems to be converse versions of some of

Beck’s Hopelessness Scale beliefs; the latter seem to tap general self efficacy. A third set of

beliefs included in this scale has to do with imbuing life and living with specific value.

Positive beliefs about Survival and Coping appear strongly related to both prior and current

suicidal behavior.

From the findings it seems warranted to conclude that suicidal individuals, when compared to

both psychologically disturbed, non-suicidal individuals, and non-disturbed, non-suicidal

persons, lack positive beliefs related to surviving and coping with life, beliefs shared by a

large portion of the population.

2. Responsibilities to family and child related concerns

Both the importance of beliefs about one’s responsibility to a family as well as concerns

about children are significantly related to whether one reports prior suicidal behavior or

currently engages in suicidal behavior. Irrespective of psychiatric status,family and child

related concerns are almost universal. Higher importance attached to Child-Related Concerns

also differentiates current suicide ideators from current parasuicides.

In addition, importance of family and children is negatively related to reported suicide

ideation for the past year, prediction of the likelihood of future suicide, and ratings of suicide

as a solution to life’s problems. Whether one communicates this suicide ideation, however,

appears related to the importance of family but not to the importance of child related

concerns.

3. Fear of suicide, fear of social disapproval, and moral objections

The Fear of Suicide Scale is the only scale that distinguishes between individuals who report

actual parasuicidal behavior in the past and individuals who report having thought about it

seriously at some point but not engaging in any overt suicidal behavior. In the general

population, people with a history of parasuicide report less fearful expectancies than do

individuals with a history of serious ideation in the absence of actually carrying out those

ideas. The high negative correlation between the Fear of Suicide Scale and social desirability

should be viewed with considerable caution; reports of prior suicidal activity are also related

to social desirability (Linehan & Nielsen, 1981).43

Presumptive Stressful Life Events Scale (Singh G., Kaur and Kaur,1984)5

The Presumptive Stressful Live Event Scale (PSLES) measures stressful events specifically

for the Indian population. The scale consists of 51 items. The scale consists of two time

scales : Life time and Past one Year as recall of events in recent time is considered better

than relatively remote events.

Beck’s Scale For Suicide Ideation (Beck,)42

The Beck’s Scale for Suicide Ideation (BSS), is a self report scale to assess severity of

suicide ideation in adults and adolescents. Each item on the scale contains three statements

and are graded in severity from 0 to 2. The first five items are screening items that limit the

length and intrusiveness of the assessment for individuals who are non-suicidal.

8

Data analysis

The cases were divided into two groups, suicide attempters and suicide non-attempters.

Demographic characteristics of both the groups were compared, chi-square and “t”-test

applied as appropriate. Similarly the scores obtained on Hamilton Depression Rating Scale,

Beck Depression Inventory, Brief Psychiatric Rating Scale, Beck’s Suicide Ideation Scale

and Presumptive Stressful Life Event Scale was compared and as appropriate “t”- test was

applied.

The total score on the Reasons for Living Inventory was compared as well as scores for the

factors, Responsibility towards family, Fear for Social Disapproval, Moral Objections,

Survival and Coping Beliefs, Fear of suicide and Child Related Concerns, was also compared

appropriately.

Analysis of data was done by using Epi-info. 43

Results

1. Demographic and Clinical Features of Patients with Major Depression

Table 1: Demographic characteristics

Suicide

Attempts

present

n=24

Suicide

Attempts

Absent

N=46

Age years

Range

Mean(sd)

22-51

34.95(9.72)

19-62

36.76(12.18)

t =0.63, df=68,

p=0.53

Sex

Male

Female

12 (50)

12 (50)

24 (52.2)

22 (47.8)

X2= 0.03,df=1,

p=0.86

Religion

Hindu

Muslim

Other

17 (70.8)

4 (16.7)

2 (8.3)

38 (82.6)

8 (17.4)

0 (0.0)

X2= 4.15,df=2,

p=0.125

Occupation

Unemployed

Student

Salaried Job

Business

Professional

14 (58.3)

1 (4.2)

2 (8.3)

4 (16.7)

3 (12.5)

19 (41.3)

5 (10.9)

16 (34.8)

5 (10.9)

1 (2.2)

X2=9.44,

df=4,

p=0.05

Residence

Urban

Rural

15 (62.5)

9 (37.5)

37 (80.4)

9 (19.6)

X2= 2.66,

df=1,

9

Table 2: Comparison of various measures in suicide attempters and non-attempters

Suicide

Attempts

present

n=24

Suicide

Attempts

Absent

N=46

‘t’ test

BDI Score

Range

Mean(sd)

12-35

22.1(6.73)

2-34

15.1(7.23)

t =3.9, df=68,

p=0.002

HDRS score

Range

Mean(sd)

12-37

24.29(6.59)

5-38

17.76(7.25)

t =3.69, df=68,

p=0.0005

SIS Score

Range

Mean(sd)

0-17

15.87(8.19)

2-34

3.91(4.82)

t =7.69, df=68,

p=0.0001

BPRS Score

Range

Mean(sd)

6-31

14.95(6.83)

2-31

9.73(6.58)

t =3.1, df=68,

p=0.0027

PSLES Score

Range

Mean(sd)

1-15

7.58(4.36)

0-20

6.65(4.70)

t =0.84, df=68,

p=0.40

Demographic characteristics:

Patient age range was 19-62 years with mean age, 36(41.4%) were men and 34(48.6%) were

women. 55(78.6%) were Hindus,12 ) %1.71(( Muslims and 2(0.3%) were others. Thirty three

patients were unemployed ,18 (25.7%) had salaried jobs , 52(74.3%) had urban background

and 18(25.7%) hailed from rural area .

p=0.1

Income

< 1000

1000-3000

3000-5000

>5000

2 (8.3)

12 (50)

7 (29.2)

3 (12.5)

15 (32.6)

14 (30.4)

8 (17.4)

9 (19.6)

X2=6.93,

df=3,

p=0.07

Education

Illiterate

Primary

Secondary

Higher Sec.

College

2 (8.3)

5 (20.8)

12 (50)

3 (12.5)

2 (8.33)

12 (26.1)

18 (39.1)

8 (17.4)

2 (4.3)

6 (13.0)

X2= 11.74,

df=4,

p=0.01

10

Forty three (61.4%) had monthly income more than Rs.3000. xorty six (65.7%) had

education upto higher secondary school ,14( 17.4 %) had no formal education and 8 (11.4%)

were college educated.

Of the 70 patients who participated in the study, 24(34.3%) had attempted suicide. Most

common mode of suicide was by ingestion of organo-phosphorus compound.

However suicide attempters and non-attempters did not differ significantly on demographic

characteristics like age, sex, religion, and income. Depressed patients who

attempted suicide were more often unemployed and were better educated.

Disease Related Characteristics:

On both subjective and objective measures of major depression, BDI and HDRS

who attempted suicide had higher mean scores .On SIS, the attempters had higher mean

score, similarly on BPRS the attempters had similar higher scores compared to non-attempters.

As regards duration of illness when patients sought treatment as outpatient varied from 1

month to 6 months. Most suicide attempters had a shorter duration of disease, which varied

from 3 weeks to 2 months.

Life events and suicide attempt:

Suicide attempters and non-attempters did not differ significantly as regards mean number of

stressful life events.

Suicide intent and Suicide attempt:

Depressed patients who attempted suicide harbored more severe suicidal ideation than those

who did not. The difference was found statistically significant.

Reasons for Living and Suicide attempt in Major Depression:

Measures From

Reasons for Living Inventory

Suicide

Attempt

N=24

No Suicide

Attempt

N=46

T statistics

Scores for Factors

Responsibility towards family

Range

Mean(sd)

3-18

25.16(8.3)

0-39

27.23(6.94)

t= 2.64,

df= 68,

p= 0.275

Fear of social disapproval

Range

Mean(sd)

6-24

10.04 (4.5)

5-18

9.4(2.9)

t= 0.73,

df= 68,

p= 0.46

Moral objections

Range

33-122

8-21

t= 0.63,

11

Mean(sd)

16.04 (5.11)

15.4(3.3)

df= 68,

p= 0.53

Survival and coping belief

Range

Mean(sd)

8-28

80.7 (22.0

61-135

100.7(13.5)

t= 4.7,

df= 68,

p= 0.0001

Fear of suicide

Range

Mean(sd)

8-28

18.4 (5.6)

0-28

15.4(6.4)

t= 1.94,

df= 68,

p=0.05

Child-Related concern

Range

Mean(sd)

3-18

10.5(5.9)

3-21

11.9 (4.6)

t= 1.09,

df= 68,

p=0.27

Total Score

Range

Mean(sd)

86-219

159.29(39.05)

128-231

182.48(21.75)

t= 2.64,

df= 68,

p=0.01

The mean of the total score on the Reasons for Living Inventory in patients who did not

attempt suicide was significantly higher compared to those who attempted suicide(182.48 vs

159.29 ) ,the difference was statistically significant.

Reasons for living Correlation with Hopelessness as well as suicide intent :

For whole MDD patients in this study, Hopelessness score and Total RFL score correlation

was significant( r = -0.255, p=0.033). Similarly Beck’s Suicide Intent Scale Score and Total

RFL score had high negative correlation ,which was statistically significant( r= - 0.508 ,

p=0.000)

In a separate analysis for suicide attempters, the total score for reasons for living was

significantly inversely correlated with the scores for hopelessness (r= -0.255, N=70, p =

0.23), suicide Intent Scale scores (r= - 0.508, N=70, p = 0.113).

Discussion

This is the first Indian study to examine the association between different RFL and suicide

ideation in adults with major depression. Prior western studies have shown that RFL are

negatively associated with suicide ideation in younger adults,18,44,45 with the exception of fear

of suicide which was found to have a negative association with suicide ideation in a clinical

sample but a positive association in a nonclinical sample.18

12

Our findings indicated that fear of suicide, as proposed by the authors of the RFL as an

combination of the fear of death and fear of the act of killing oneself, diminishes the

likelihood of suicide ideation in adults with a mood disorder. The fear of death and of

killing oneself may be an important deterrent of suicide ideation in depressed adults. None

of the other RFL was associated with the presence or severity of suicidal ideation.

Findings of this study regarding patients with Major Depressive Disorder are consistent with

results in previous studies of Major Depressive disorder by Malone et al and of Borderline

Personality disorder by Lineham et al, in which more reasons for living in depressed patients

protected against acting on suicidal thoughts at vulnerable times. 18, 35

In a Pearson correlation analysis, the total scores for reasons for living were significantly

correlated with the scores for hopelessness and suicidal ideation. This means that as the

reasons for living increases hopelessness decrease and similarly for suicidal ideation.

Thus the study shows that the reasons for living does have a protective role in major

depression and protects patient from committing suicide.

The individual scores for factors on Reasons for Living Inventory differed from the study

conducted by Malone et al on western subjects.

Chils et al(1989)in their comparative study of American and Chinese patients who were

having difficulty with suicidal thinking or behavior found that Hopelessness, reasons for

living, and suicidal efficacy showed none of the expected relationships with suicidal intent

among the Chinese patients, but the two groups were similar on many variables theoretically

related to suicidality. Chinese patients were less likely to communicate suicidal intent and

rated suicide as less effective at solving problems. The authors emphasize possibility of

different cultural approaches to suicidal behavior. 43

Reasons for living, like hopelessness,

may reflect a cultural or environmental component in the suicide threshold and may

contribute to variation in suicide rates among different cultures (Malone et al, 2000). 35

As a whole those who attempted suicide had significantly lower scores on RFLI compared to

those who did not attempt suicide. In other words, those who had more reasons to live ,

attempted suicide less often and vice versa. Non-attempters had higher scores on Survival and

Coping Beliefs as well as Fear of Suicide. Both the findings were in line with study by

Malone et al.

Contrary to Malone et al, in the present study, the scores for Responsibility towards Family,

Fear of Social Disapproval, Moral Objections and Child Related Concerns were similar

among suicide attempters and non-attempters, the difference being not statistically

significant.

Depressed patients who attempted suicide had experienced similar number of stressful events

comparable to those who did not attempt suicide. Thus merely presence of a stressful event

may not be sufficient to lead to suicide attempt; the meaning of the event may be much more

significant for such outcome. Malone also did not find excess stressful life events in MDD

Patients who attempted suicide.

In general, RFL may reflect a sense of purpose and meaning, 46 that makes people live through

difficult circumstances. However RFL involving family obligations may enhance the

negative effects of hopelessness. Clearly, more research on the apparently complex relations

between responsibility to family, hopelessness, and suicide ideation is needed.

13

Implications: Clinicians while interviewing for suicide risk factors , should also explore the reasons for

living. What each RFL means for each patient is important, rather than assuming that they are

protective. Understanding the personal meaning of RFL may improve clinicians’ ability to

evaluate whether RFL are indicative of resilience or risk. Open-ended questions about

specific RFL may encourage patient elaboration and reveal critical details and insights that

could improve clinicians’ ability to determine risk. This exploration may also enhance

patients’ understanding of their motivation to live.

Limitations:

Small sample size and recall bias might be considered as possible drawbacks of the study.

Conclusion

This study concludes that occupation, higher education, fear of suicide, social and coping

beliefs of individuals and society at large act as protective factors against suicide in patients

with current Major Depressive Disorder. Severity of depression was significantly higher in

suicide attempters. Life events as opposed to the conventional thought were not higher in the

suicide attempters and thus made little impact.

Sources of support: None Conflict of interest: None

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Sources of support : None Conflicts of interest: None

Vikas Malik, MD, Resident ,

Psychiatry Dept.,Medical College and SSG Hospital,Vadodara

Rachana Pole, M.B.B.S.Resident

G.K.Vankar,MD,DPM, Professor and Head

Department of Psychiatry,B.J.Medical College and Civil Hospital,Ahmedabad 380016

Correspondence:

Dr.G.K.Vankar Professor and Head

Department of Psychiatry, Civil Hospital OPD Building ,Wing 1, First Floor Asarawa,

Ahmedabad 380016

e-mail:drgkvankar@gmail.com

cell:+919904160338