· Adolescents not falling under the age range

· Adolescents having severe forms of psychiatric and medical conditions

· Adolescents with high hopefulness, optimism, self-esteem, self-efficacy

· Adolescents having an increased level of mindfulness

· Those who were not referred

· Who did not give written informed consent

Tools used

1) Socio-Demographic and Clinical Data Sheet- Participant's details concerning their clinical and personal information was collected using semi-structured clinical and personal datasheet.

2) General Health Questionnaire-12- It was used to assess the general mental health of individuals ^[12].

3) Beck Hopelessness Scale: It was developed by Aaron Beck and was a 20 items scale. Scores 0-3 was none or minimal hopelessness, 4-8 was Mild, 9-14 was Moderate and 15+ is Severe ^[13].

4) Life Orientation Test-Revised (LOT-R)- A 10-item measure of optimism versus pessimism. Of the 10 items, 3 items measure optimism, 3 items measure pessimism, and 4 items serve as fillers. Respondents rate each item on a 4-point scale: 0 = strongly disagree, 1 = disagree, 2 = neutral, 3 = agree, and 4 = strongly agree. LOT-R is a revised version of the original LOT. The original LOT had 12 items: 4 worded positively, 4 worded negatively, and 4 fillers ^[14].

5) General Self-Efficacy (GSE)- This scale was developed by Jerusalem and Schwarzer. He first developed originally the German version of this scale as 20-items and later he translated this scale into German to English and reduced 10-items. After a short period, Sud (2002) also translated this scale from English to Hindi version. Therefore, general self-efficacy scale (Hindi version) consists of 10-items rated on a four-point rating scale with the response categories i.e. (1), not at all true, (2) hardly true, (3) moderately true, and (4) exactly true. For scoring, all the ten items are added to yield the final composite score with a range from 10-40. The reliability coefficient of the scale was found to be ranging from 0.76 to 0.90 ^[15].

6) Rosenberg Self-Esteem Scale- It was a 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. The scale is believed to be uni-dimensional. All items are answered using a 4-point Likert scale format ranging from strongly agree to strongly disagree ^[16].

7) Adolescent Psychological Resilience Scale- This scale consists of 29 items, to be rated on 4 point rating. It assesses 6-factors, i.e. family support, confidant-friend support, school support, adjustment, sense of struggle and empathy ^[17].

8) Five Facet Mindfulness Questionnaire (FFMQ)- It was a 15 items scale, with the 5-point rating. The higher the score, the higher is the mindfulness ^[18].

Procedure- Total of 45 patients suffering from acne, eczema and psoriasis were referred from Dermatology OPD for psychological management (therefore, no ethics committee was held for this specifically). Patients with severe eczema and psoriasis were also referred from the Department of the Radiotherapy after ruling out cancer. Since the participants were minors, their written informed consent was obtained from their parents or guardians. After obtaining permission, detailed assessment was done using above mentioned tools; they were also explained about the purpose of the study and the amount of time it will require, i.e. 6 weeks (weekly session). These 45 participants were then randomly divided into an experimental group and waitlist group. The experimental group consisted of 23 participants and waitlist group consisted of 22 participants. The experimental group was given acceptance and mindfulness-based intervention along with medication, whereas the waitlist group was the one who did not receive any kind of psychological intervention; they were only on medication prescribed by the Dermatology OPD. The waitlist group was informed that they will be given psychological intervention after 1½ months.

The intervention was given in Psychological research lab of the psychiatry department, JNMC&H, AMU, up to 6 sessions for the next 1^1/2 months, asking them to visit weekly. For patients in the waitlist group, only pre and post-assessment were done for the next 1^1/2 months. They were given TAU. After completion of therapy, the above-mentioned scales were reassessed to see the effect of acceptance and mindfulness-based intervention (Experimental and Waitlist). The level of mindfulness was assessed immediately after every session (only the experimental group). Patients in the waitlist group were given psychological intervention after the termination of the experimental group’s therapy.

Statistical Analysis- The statistical analysis was done using the Jeffreys's Amazing Statistics Program (JASP) ^[19]. Percentage (%) is used to see the proportionate part of the total sample (socio-demographic and clinical data). the t-test is used to compare between both the groups to see the effect of acceptance and mindfulness intervention on psychosocial factors after pre and post-intervention.

Ethical approval details- The patients were referred from the Department of Dermatology and Radiotherapy for Psychosocial Management to Psychiatry OPD. The intervention was carried out in the Departmental of the research lab.

RESULTS- Fig. 1 shows the socio-demographic as well as clinical details of experimental and waitlist group. Most of the adolescents in both groups were females (Experimental=69%; Waitlist=72%), falling under the age range of 13-17. Maximum adolescents were high-school students (Experimental=56%; Waitlist=54%). Maximum patients were from middle class (Experimental=52%; Waitlist=50%), residing in urban area (Experimental=69%; Waitlist=64%). Most of the patients were receiving treatment for the past for more than 6 months (Experimental=56%; Waitlist=54%).

Fig. 1: Socio-demographic and clinical details of all the participants

Table 1 shows the difference between scores of experimental group post-intervention on hopelessness, optimism, self-efficacy, self-esteem and resilience. Transformation of hopelessness scores from pre-intervention (M=10.82) to post-intervention (M=2.91) was indicative of how AMBI has increased patients hope. Similarly, changed scores of optimism pre-intervention (M=4.04) to post-intervention (M=18.73) was also indicative of the result of AMBI as a treatment was effective enough for changing patients pessimism into optimism. Significant t-values of self-efficacy (t=13.87) and self-esteem (t=24.61) also indicated a similar effect i.e. uplifting patients self-efficacy and self-esteem. Pre-intervention scores (M=30.13) and post-intervention score (M=90.21) of resilience also indicates that AMBI not only improves hampered psychosocial factors of patients with skin conditions but also helps in restoring their fighting spirit (resilience).

Table 1: The M, SD and t-values of the experimental group

Variables	Intervention	M	SD	t-value	p-value
Hopelessness	Pre	10.82	1.61	35.02	<0.001*
Hopelessness	Post	2.91	0.9	35.02	<0.001*
Optimism	Pre	4.04	1.75	24.71	<0.001*
Optimism	Post	18.73	2.32	24.71	<0.001*
Self-Efficacy	Pre	13.52	1.99	13.87	<0.001*
Self-Efficacy	Post	29.95	5.21	13.87	<0.001*
Self-Esteem	Pre	14.43	5.21	24.61	<0.001*
Self-Esteem	Post	38.78	2.39	24.61	<0.001*
Resilience	Pre	30.13	2.68	21.63	<0.001*
Resilience	Post	90.21	13.6	21.63	<0.001*

*sig. at 0.05 level

Table 2 shows that there was no significant difference was found between pre-intervention and post-intervention scores of waitlist group on hopelessness, optimism, self-efficacy, self-esteem and resilience.

Table 2: The M, SD and t-values of waitlist group

Variables	Intervention	M	SD	t-value	p-value
Hopelessness	Pre	10.86	1.32	2.66	0.01
Hopelessness	Post	10.4	1.29	2.66	0.01
Optimism	Pre	4.04	2.05	0	1
Optimism	Post	4.04	1.73	0	1
Self-Efficacy	Pre	13.36	2.15	0.43	0.66
Self-Efficacy	Post	13.59	1.81	0.43	0.66
Self-Esteem	Pre	13.22	2.7	2.18	0.04
Self-Esteem	Post	12.09	1.63	2.18	0.04
Resilience	Pre	30.59	2.88	2.97	0.007
Resilience	Post	29.95	2.68	2.97	0.007

*sig. at 0.05 level

Table 3 and Fig. 2 show a significant difference between groups (Experimental and Waitlist) post-intervention. Difference between experimental and waitlist group on hopelessness was M=2.91 and M=10.4 respectively, indicating that AMBI was effective enough to improve patients hopelessness level and converting it into hopefulness. A similar result was found on optimism variable, i.e. M=18.73 (experimental) and M=4.04 (waitlist). Significant t-values of self-efficacy (14.43) and self-esteem (26.43) variables of the experimental group also indicate a similar result of the effectiveness of AMBI. The difference in resilience of the experimental group (M=90.21) and waitlist group (M=29.95) is also indicative of the efficacy of AMBI. The overall improvement is suggestive of how AMBI helps in the improvement of various psychological factors affected by different skin conditions when the comparison is made between waitlist and experimental groups.

Table 3: Post-intervention difference between the experimental group and waitlist group on various psychosocial domains

Variables	Group	M	SD	t-value	p-value
Hopelessness	Experimental	2.91	0.9	35.01	<0.001*
Hopelessness	Waitlist	10.4	1.29	35.01	<0.001*
Optimism	Experimental	18.73	2.32	24.43	<0.001*
Optimism	Waitlist	4.04	1.73	24.43	<0.001*
Self-Efficacy	Experimental	29.95	5.21	14.43	<0.001*
Self-Efficacy	Waitlist	13.59	1.81	14.43	<0.001*
Self-Esteem	Experimental	38.78	2.39	26.43	<0.001*
Self-Esteem	Waitlist	12.09	1.63	26.43	<0.001*
Resilience	Experimental	90.21	13.6	20.29	<0.001*
Resilience	Waitlist	29.95	2.68	20.29	<0.001*

*sig. at 0.05 level

Fig. 2: Comparison and effect of acceptance and mindfulness-based intervention on experimental and waitlist group

Table 4 and Fig. 3 shows the level of mindfulness has increased for both the groups from pre-intervention to post-intervention. Pre-intervention of AMBI, mindfulness level of the experimental group was M=30.34 and waitlist group was M=30.31. But after mindfulness intervention (only to the experimental group), it was found that for the experimental group it increased (M=92.17) while for waitlist group mindfulness level remain static (M=30.13). The statistical analysis indicates mindfulness is an effective technique that improves psychosocial factors associated with skin conditions as well as increases the patient's mindfulness level.

Table 4: The level of mindfulness (mean values) of the experimental and waitlist group (pre and post-intervention)

Intervention	Experimental Group	Waitlist Group	t-value	p-value
Pre-Intervention	30.34	30.31	0.38	0.7
Post-Intervention	92.17	30.13	20.27	<0.001*

*sig. at 0.05

Fig. 3: Level of mindfulness of experimental and waitlist group

DISCUSSION- Psychosocial factors significantly affect the skin of the human being. Adolescents are more prone to skin problems as there have been changes in their hormones resulted in acne. High levels of psychological problems were documented in studies. Studies have indicated that 30-70% of people suffer from skin conditions ^[2-4]. Over the years, various researches have been done to see the effect of mindfulness-based interventions on physical conditions ^[20]. P D’Alton et al. ^[21]have explored the association between the mindfulness-based intervention and skin diseases and has found significant improvement among the patients.Our present study supported the previously done study. In our study, it was seen that patients with different skin disorders gradually showed improvement in all aspects of psychological factors.

The present study assesses the level of hopelessness, optimism, self-efficacy, self-esteem and resilience among adolescents suffering from dermatological problems (acne, eczema and psoriasis). Having skin problems increase distress in adolescents. Our pre-intervention assessment data indicates that before giving intervention, psychosocial problems were high. Fordham et al.^[22] found in their study that eight–week mindfulness was an effective treatment for people with psoriasis. The present study supports the previous study and found acceptance and mindfulness therapy significantly improve self-efficacy and self-esteem and also improved quality of life. Our study further explores the effect of acceptance and mindfulness-based intervention (AMBI) on the level of mindfulness. After every session mindfulness was assessed and found gradually improvement (mindfulness) in experimental group patients.

There’s a lack of studies that assess the level of hopelessness, optimism, self-efficacy, self-esteem and resilience among people suffering from skin conditions. In the present study, it was found that the level of hopelessness was more before the intervention but as the AMBI took place their hopelessness changed into hopefulness. Likewise, pessimism changed into optimism when the intervention was given. Self-efficacy, self-esteem and resilience have been reported to be restored after the successful intervention, which was on the lowest side ^[23,24].Various studies addressed that AMBI provides relief from various psychological distresses. One other study was done by Montgomery et al. ^[25] it was found that mindfulness helps reduce psychological distress. This study was conducted on adult dermatology patients. The present study shows significant improvement in making patients self-efficient, increase their self-esteem and improve mindfulness and quality of life, help them maintain their mental hygiene with skin conditions.

The result explains how mindfulness level increased as the intervention took place, hence supporting previously conducted study by where they conducted a meta-analysis to prove how mindfulness-based therapies are effective in the treatment of various conditions and psychosocial factors associated with it ^[26].

CONCLUSIONS- Acceptance and mindfulness-based therapy is an effective, non-pharmacological approach towards treatment of psychosocial aspects related to skin conditions in adolescents and this therapy has also been very helpful in increasing the level of mindfulness in them. The present therapy is proved itself that it increased positive behaviours while feeling low due to negative thoughts. This therapy is easy to understand, can be regularly practised at home without the constant guidance of the therapist and as the patient learns the therapy during the session it can also help to reduce future relapse. The present therapy is cost-effective and the therapy itself has no side-effects.

In psycho-education, detail explanation was given that this therapy is not only limited to negative psychosocial aspects to skin diseases but would also prove to be beneficial in future to all aspects related to mental health.

CONTRIBUTION OF AUTHORS

Research concept- Dr. Deoshree Akhouri

Research design- Dr. Deoshree Akhouri

Supervision- Dr. Deoshree Akhouri

Materials- Dr. Mohammad Akram, Dr. Deoshree Akhouri

Data collection- Dr. Deoshree Akhouri, Maria Madiha

Data analysis and Interpretation- Dr. Deoshree Akhouri, Maria Madiha, Dr. Mohammad Akram

Literature search- Dr. Deoshree Akhouri, Maria Madiha

Writing article- Dr. Deoshree Akhouri, Maria Madiha

Critical review- Dr. Mohammad Akram, Dr. Deoshree Akhouri

Article editing- Dr. Deoshree Akhouri, Dr. Mohammad Akram

Final approval- Dr. Deoshree Akhouri, Maria Madiha, Dr. Mohammad Akram

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Research Article (Open access)