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Challenges of the Stress Check System

Shinobu Nomura
Professor, Faculty of Human Sciences, Waseda University


 As an increasing number of people complain about their physical and mental conditions due to stress from overwork, there is a call to examine mental health at the workplace. With this in mind, the implementation of the stress check system, the first of its kind in the world, began under Japan’s revised Industrial Safety and Health Law in December 2015. This is an innovative measure to prevent a breakdown in people’s mental condition, and each business is earnestly striving to implement this system; however, at the same time, various problems are emerging. This article discusses the current challenges and measures to be taken with a focus on four points: (1) stress and illness, (2) stress check tools, (3) standards for judging who is highly-stressed, and (4) cooperation between industrial physicians and external organizations.

Stress and illness

Dr. Hans Selye, who is known for his stress theory, said, “Stress refers to physiological and psychological distortions that occur in the living body, and stress is generated by externally added stressors.” When stressors are added, psychological (anxiety, tension, hypersensitivity, depression, impatience, confusion, and other emotional changes), physical (fatigue, weariness, headache, palpitations, difficulty in breathing, and other autonomic reactions), and behavioral (drinking, smoking, eating, and other changes in lifestyle) stress reactions are observed. These stress reactions are essentially a defense system of the living body, but if stressors become excessive or continue chronically over a long period of time, the mind and body become totally exhausted, resulting in poor physical condition or some kind of illness. However, the way stressors are recognized, the way the reactions appear, and the way it should be coped with vary from one individual to another, and it is difficult to assess these matters in a uniform way. To date, a wide range of physiological and psychological stress assessment methods have been devised, but none are definitive, and the choice of method depends on what is considered to be the best according to the purpose of the stress assessment.

Stress check tools

In its manual for the implementation of the stress check system, the Ministry of Health, Labour and Welfare (MHLW) recommends a simple occupational stress questionnaire as a stress check tool. This questionnaire is a Japanese version of the Generic Job Stress Questionnaire developed by the United States’ National Institute of Occupational Safety and Health (NIOSH). MHLW’s questionnaire consists of 57 items: 17 for workplace stressors, 29 for physical and mental stress reactions, and 11 for buffering factors (such as social support). It is simple and easy, and research is being conducted in various areas.

The implementation manual encourages businesses to identify highly-stressed people using this questionnaire, but the definition of “highly-stressed people” is unclear, which is somewhat problematic. The manual operationally considers people whose mental and physical stress reactions exceed a certain reference point as being “highly-stressed people,” but there is a problem of equating conscious mental and physical symptoms with stress reactions. Strictly speaking, only mental and physical reactions that arise from a number of stressors should be considered as stress reactions. In addition, the manual limits stress to workplace stress, controversially not taking into consideration individual factors, family environments, and other stressors.

Incidentally, businesses are allowed to choose stress check tools other than the simple occupational stress questionnaire mentioned above, and they are advised to decide what tool they should use based on discussions at the health committee of their business sites. In this case, the tool should cover at least the following three areas: (1) job stress factors, (2) mental and physical stress reactions, and (3) support provided.

There are many businesses which have been conducting stress checks since early on, and in such cases, it is important to continue using the previous tool in an ongoing manner, so that long-term changes can be analyzed.

Standards for judging highly-stressed people

When implementing the stress check system, businesses are expected to decide the implementation system and method along with other details, based on the opinions of the implementers (mainly, industrial physicians and nurses) and the discussions by the health committee. Furthermore, the health committee is placed with even heavier responsibility to set standards for judging who is highly stressed. It is important that implementers familiar with the stress check system propose methods that reflect current conditions at each business site.

The judgment standards for highly-stressed people define them as such if their mental and physical stress reactions exceed a certain point, but in addition, including scores for “work environment factors and (lack of) support” could cause confusion. If such standards are followed, people who do not show serious stress reactions but are dissatisfied with work could be judged as highly-stressed. Experiences at some businesses indicate that in guidance interviews, the discussions focused only on how to improve the workplace rather than talking about stress.

Recommended, but only a few request an interview

Data shows that although recommended, only a few people judged as highly stressed actually request an interview (it is estimated that highly-stressed people account for 10% of total examinees, and some data indicate that approximately 3% of those people request an interview. Therefore, the percentage of highly-stressed people interviewed to total examinees is only 0.3%!). While introduced with much effort, the stress check system unfortunately may not produce satisfactory results. The reason why this occurs is because of the prerequisite for interview requests, which asks to disclose the results of stress check, constituting an obstacle to the system. It is understandable that highly-stressed people do not want their company to know about their mental problems, and in this respect, the system needs to be revised. In other words, considerable improvements can be expected if the results of stress checks for highly-stressed people do not need to be disclosed at the stage of interviews for guidance. This will make interviews more accessible, and the consent to disclose stress check results can be obtained when, as a result of interviews, the interviewer feels it is necessary.

Cooperation between industrial physicians and external organizations

The roles of industrial physicians consist of industrial health activities, such as: participating in the health committee, visiting workplaces, improving work environments, conducting health examinations, taking post-examination measures, interviewing employees about overwork and submitting job-related opinions. However, industrial physicians are assuming heavier responsibilities as professionals who have implemented the new stress check system, and this has been pointed out as a major problem. Because industrial physicians are not specialists in handling mental health cases in areas other than psychiatry and psychosomatic medicine, there are serious concerns for the burden taken on when conducting stress checks, the duties assumed in guidance interviews, and the heavier responsibilities shouldered on them.

If industrial physicians can properly conduct stress checks and perform duties such as recommending interviews, holding guidance interviews, and paying attention to job-related matters in a comprehensive manner, there would not be any problems; but in reality, due to a lack of industrial health staff or their not being sufficiently trained, it difficult to say that they are meeting every demand. In that case, industrial physicians need to cooperate with external resources (such as medical institutions, local industrial health centers, and EAP service providers) when implementing the system. In doing so, it is desirable not to farm out all duties to external contactors but fully cooperate together as partners.


Stress checks are an innovative system which is expected to bring satisfactory results by preventing mental breakdowns, detecting any early signs of mental instability and taking measures to help such people as soon as possible. However, many businesses are perplexed as they face various issues mentioned above.

Hopefully, the stress check system will improve by taking the actual situation of workplaces into account and meeting their needs.


Ministry of Health, Labour and Welfare’s implementation manual for the stress check system

Shinobu Nomura
Professor, Faculty of Human Sciences, Waseda University

Professor Shinobu Nomura graduated from Kobe University with a bachelor’s degree in medicine in March 1977. His areas of expertise are psychosomatic medicine, behavioral medicine, and clinical psychology. Professor Nomura had served as an assistant professor at the University of Tokyo’s Department of Psychosomatic Medicine starting in 1996 before becoming a professor at the Faculty of Human Sciences in April 2002. He is also the president and advisor of the Japanese Society of Behavioral Medicine, director of the Japanese Society of Psychosomatic Medicine, director of the Japanese Association of Stress Science, director of the Japanese Association of Job Stress Research, and councilor of the Japanese Association of Medical Sciences (He has taken important posts at many other societies and associations). Professor Nomura’s major publications include: An Introduction to Psychosomatic Medicine (written and edited), Kaneko Shobo; Stress Management in the Information Age, Nippon Hyoron Sha; The Latest Knowledge in Psychosomatic Medicine (written and edited), Nippon Hyoron Sha; and Behavioral Medicine Textbook (written and edited), Chugai Igakusha.