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:[email protected]
cell:+919904160338