2025 Volume 11 Issue 1 Pages 2-11
In occupational health, mental health measures in the workplace are classified into three categories: primary, secondary, and tertiary prevention of mental health problems. The tertiary prevention aims to provide appropriate support for the return to work of workers who have been absent from work for a long period of time, prevent recurrence or relapse of the illness, and promote readjustment to the workplace. However, there have been some problems in determining whether or not to provide such support. Rework programs are now being implemented at medical facilities. These programs are mainly for workers who have depression or are in a depressed state; however, it has been recently pointed out that symptoms of depression are becoming more diverse and the developmental characteristics of users should be paid attention to. Our hospital opened a rework daycare center in November 2007 and has been supporting, in collaboration with their attending physicians and workplace, the return to work of those who have taken a leave of absence. This study reviews those efforts to date and discusses future issues to be addressed.
In Japan, in response to the increasing number of patients with mental disorders, the Ministry of Health, Labour and Welfare (MHLW) has established a medical scheme of five diseases and five projects since 2013, adding mental disorders as a new priority measure. In 2024, the medical scheme became 5 diseases and 6 projects, after the addition of "Basic policies for novel coronavirus disease control." 1) Measures for the treatment of mental disorders remain a major issue in Japanese healthcare. However, measures for workers' mental health have long been considered important in the field of occupational health, and related laws have been amended several times to prevent, detect, and respond early to workers' mental health problems and support the return to work of those on leave of absence. The author will describe the guidelines issued by the government, the status of implementation at medical facilities, and future issues regarding efforts to support the return to work of workers on leave, which is positioned as tertiary prevention.
In occupational medicine, the concept of health promotion is presented as preventive medicine. This concept is known as one of the five stages of prevention: (1) health promotion, (2) specific protection, (3) early diagnosis and prompt treatment, (4) disability limitation, and (5) rehabilitation, as presented by Leavell and Clark in the USA in the 1950s.
This is one of the models that presents a framework for collaboration between practitioners and public health workers who are responsible for community healthcare.2)
Occupational health in Japan has introduced the concept of preventive medicine into health management activities, dividing them into primary, secondary, and tertiary prevention. Primary prevention targets a group of healthy people and aims to prevent the onset of disease and occurrence of injury. Secondary prevention targets include high-risk individuals and suspected cases of disease onset and aims to prevent serious illness and maintain work capacity through early detection and early treatment. Tertiary prevention targets preexisting patients and aims to prevent recurrence, avoid death, restore labor capacity, and enable patients to return to work.3)
In March 2006, MHLW issued "a guideline for improvement of preservation of worker' s mental health," which calls for the promotion of mental health measures in the workplace through a wide range of activities. These activities range from primary to tertiary prevention.4,5)
In October 2004, MHLW issued a guideline on support for returning to work, which was revised in March 2009 and is still in use today. The guideline highlights the need to advance the return to work (rework) process, in order for workers who have been absent from work with mental health problems to return to work smoothly. The rework support guide based on this guideline comprehensively outlines the content of rework support to be provided by employers when workers actually return to work.6)
In this guide, the flow of support for returning to the workplace is shown as five steps. Following a diagnosis by the attending physician (the second step) that the worker can return to the workplace, the workplace makes a decision on whether or not the worker can return to the workplace (the third step), and then a rework support plan is created. After the worker who has taken a leave of absence has completed this rework support plan, a final decision is made (the fourth step), and the worker returns to work. After the return to work, follow-up is conducted (the fifth step) (Fig. 1).
The flow of return to work support
The process of determining whether a worker can return to work is as follows: after the attending physician gives his/her opinion that the worker can return to work, the industrial physician gives the opinion on whether the worker can return to work or not, and the human resource department makes a decision. The main factors to be evaluated by the attending physician regarding the return to work of a worker who has taken a leave of absence are as follows: (1) improvement of the worker' s mental status and physical condition, (2) establishment of a rhythm in his/her life, (3) the worker' s willingness to return to work, and (4) the family' s wishes. The main factors evaluated by the occupational physician are as follows: (1) improvement of work ability, (2) possibility of readjustment to the workplace, (3) effect on the workplace, (4) work based necessity, and (5) safety issues.7)
One of the most serious problems that plague those involved in the workplace is the decision to return to work for workers who have taken a leave of absence with mental health problems and the subsequent follow-up. This is because there are many cases in which workers return to work only to find that their condition worsens immediately and they are placed on leave again or that they repeatedly take leave and return to work. In addition, it is said that even after a return to work, the workplace may hold on to the employee without actually making him or her an asset to the company.8) There are two factors that contribute to this problem: (1) the worker and management do not always agree on the decision to return to work and the decision is often made in an ambiguous manner and (2) the decision is made emotionally or the permission to return to work is granted easily without a sense of risk management. Factors on the attending physician' s side include the fact that there are doubts about the validity and reliability of the medical report that serves as the basis for judgment and that the physician does not judge the patient' s realistic ability to work based solely on the evaluation of the patient' s mental health condition. In principle, the ability to return to work required by the workplace is that the worker has recovered to the point where he or she can tolerate normal work.
In response to these issues, a medical perspective of the concept of rework readiness9) was proposed by Akiyama in 2009. He reported that the general criteria for return to work are as follows: (1) psychiatric symptoms have improved, (2) no disruptive behavior in the workplace, (3) ability to perform expected tasks, and (4) no recurrence of psychiatric symptoms even if engaged in expected tasks. Rework programs are designed to improve rework readiness with both physical and other treatments.
The depression rework program can be summarized as follows: (1) group therapy: a program to improve social adjustment for working adults who have become depressed or are in a depressive state due to exhaustion from overwork or workplace stress; (2) rework readiness, a program to fill in the gaps and increase readiness for returning to work; and (3) recurrence prevention and self-care, the goal is not only to return to work but also to promote human growth and enable self-care to prevent recurrence after returning to work. This core program is designed based on the conditions that must be met by workers who have mentally and physically recovered to the point where there are no problems in returning to work, as described in the aforementioned support guidelines. The rework program makes it possible to determine whether these requirements have been met. In other words, the possibility of returning to work can be accurately determined by assessing rework readiness through a rework program.
The rework program aims to prevent recurrence of depression after return to work. To date, two papers examining this prevention of recurrence have been published. In a survival analysis using the Kaplan–Meier method, Horii et al. reported that 12 of 56 subjects (21.4%) took leave again during the study period and the average duration of work continuation estimated by the method was 715 days.10) Igarashi also compared two groups matched by propensity score for major depressive disorder and reported that the median for the usual treatment group was 122 days, while the rework group showed a clearly significant difference of 686 days.11)
In November 2007, the hospital opened a daycare center that offers a rework program. In the beginning, the daycare operated only 3 days a week, but in May 2008, it began operating 4 days a week, and in April 2009, it obtained approval as a large-scale daycare with appropriate staffing and began operating 5 days a week. In October 2013, it began a follow-up short-care program for members who had already returned to their workplaces. In addition, a new program for users with developmental disorder characteristics was implemented in January 2020. The daycare staff consists of one occupational therapist, two nurses, two psychiatric social workers, two nonexclusive clinical psychologists, and two nonexclusive psychiatrists.
Our daycare program aims (1) to restore a well-balanced lifestyle in order to allow users to return to the workplace, (2) to provide support to prevent relapse in order to allow users to continue their professional lives, and (3) to encourage users to help each other through interaction. The three pillars of the program are (1) recovery of basic abilities such as lifestyle, basic work skills, and physical strength, (2) prevention of relapse such as understanding of the disease and learning how to cope with stress, and (3) empowerment of members to support each other and recover and improve their communication skills12) (Fig. 2).
Component of the rework program
The latest statistics show 884 (684 male and 200 female) daycare users since the center opened until the end of March 2024. The most common residence of users was Sakura, where our hospital is located, followed by Chiba and Yachiyo, lastly Funabashi and Narita, which are nearby Sakura. Public employee was the most common occupation, followed by manufacturing, unemployed, information and telecommunications, and complex services industries. The most common diagnosis was depressive episode, followed by bipolar affective disorder, adjustment disorder, and other anxiety disorders. After attending the program, 56% of users achieved a return to work, 14% transitioned to rehabilitative work in the workplace, 2% changed jobs, and 3% were referred to other treatment or rehabilitative facilities. Among 727 participants whose objective was to return to work, 72% achieved a return to work (Fig. 3).
Characteristics of participants in the rework program males, 684 (77.4%); females, 200 (22.6%); end of March, 2024
A schematic diagram shows how our rework daycare collaborates with the attending physician and the workplace (Fig. 4). Three community resources are available to workers on leave and their families: the workplace and the occupational physician, the attending physician, and the daycare center that implements the rework program. The program, as already mentioned, provides rehabilitation to increase rework readiness. After reconciling the issues identified in the rework program with those in the workplace, efforts are made to prevent relapse. Family members are requested to participate in the family support program, and support that can be provided at home is discussed. In addition, group cognitive-behavioral therapy, counseling, and psychological testing are conducted, followed by referral to psychologists in the psychiatric outpatient department of the hospital as needed. Moreover, the role of the attending physician is to determine when the patient can return to work and to provide an opinion on matters that should be considered at that time. The role of the workplace and occupational physician is to determine whether or not the employee can return to work based on the attending physician' s opinion, create a rework support plan, and consider the issues that need to be taken into account. Each resource element collaborates with the others through the exchange of information, such as letters of referral and opinion forms, and rework program activity reports.
Collaboration network of a rework program at Sakura hospital
We have looked at the theory and practice of a rework program for workers who have taken leave of absence. There have been studies conducted from the standpoint of the attending physician that have investigated what factors can contribute to achieving a return to work. In a 2016–2017 workers' accident disease clinical study, research related to support methods focused on the caseness among the workers with mental health disorders in the workplace was conducted. The authors, among whom Hiro was the principal investigator, conducted a survey of the outcomes for patients with mental health disorders from the standpoint of attending physicians and their responses. The results showed that the factors identified as contributing to a successful return to work were as follows: (1) the illnesses of major depression and bipolar disorder, (2) intervention by occupational health staff, (3) good acceptance at the workplace, (4) consideration of workload, (5) collaboration with the occupational physician, (6) good family relationships, (7) good neighborhood relations, and (8) support from family members.
Risk factors associated with an inability to return to work included (1) genetic factors, (2) presence of some biological factor, (3) frequent job changes, and (4) symptom relapse. There were no statistically significant differences in medication, type of psychotherapy, use of rework programs, time to symptom improvement, or time to return to work.13) Based on these results, the points that should be considered when developing the guidelines are as follows: (1) upon achieving a return to work, it should be confirmed again that work performance has recovered, (2) the number of job changes is a risk factor for the taking of leave, (3) the usefulness of early screening and intervention for workplace adjustment should not be overlooked, (4) the intervention of workplace staff and the implementation of rework support programs is crucial, (5) collaboration with the attending physician and occupational physician increases the return to work success rate, (6) the relationship between the family and neighbors of the worker on leave is a factor for successful return to work, (7) obtaining support from family increases the return to work rate, and (8) there are different pathological conditions within the illness of depression that should be taken into account.
The rework program has been implemented to support the return to work for workers on leave with depression and to prevent recurrence; however, in recent years, our staff has become aware of the diversification of depression pathologies and the increase in users with developmental disorder characteristics. Fig. 5 shows data comparing the diagnostic classification of users from April 2008 to March 2009, when the daycare was established, and from April 2021 to 2022, the recent period. While depressive episode (F32) accounted for 59% of the total at the time of the daycare' s opening, in recent years, this has decreased to 42%. Bipolar affective disorder (F31) has increased to 11%, other anxiety disorders (F41) and adjustment disorders (F45) have increased to 30%, and developmental disorders combined with pervasive developmental disorder (F84) and hyperactivity disorder (F90) have increased to 14%. This may be a reflection of the realization that few reworkers have developmental disorder characteristics and depression pathologies are becoming more diverse.
Data indicating the relation between developmental and depressive disorders
To ascertain whether the pathologies of users have changed over time, a survey was conducted on the characteristics of the users since the opening of the daycare. There were 852 subjective users, consisting of 661 males and 191 females, in the following diagnostic categories: depressive episode (F32) 523 (61.4%), adjustment disorder (F43) 78 (9.2%), bipolar affective disorder (F31) 74 (8.7%), other neurotic disorders (F48) 52 (6.2%), other anxiety disorders (F41) 40 (4.7%), schizophrenia (F20) 33 (3.9%), developmental disorders (F84, F90) 28 (3.3%), and others 24 (2.8%). The starting age was 51.2 ± 10.2 for males and 43.9 ± 11.3 for females, for a total of 51.1 ± 10.3 years old; the duration of daycare use was 183.9 ± 121.1 for males and 178.0 ± 130.1 for females, for a total of 181.0 ± 122.3 days; and the duration from leave of absence to daycare use was 212.8 ± 188.6 for males and 201.5 ± 254.2 for females, for a total of 193.2 ± 207.6 days (±SD). We divided this group into two groups, one for the first 10 years from 2007 to 2017 and the other for the last 5 years of users from 2018 to 2023, and compared their data (Fig. 6). The average age at the start of use of the first group was 51.6±10.1 years, while that of the second group was 43.5±11.4 years, indicating that more younger members were using the program. In terms of diagnosis, an increase in bipolar disorder was not shown, while adjustment disorder, anxiety disorder, and developmental disorders increased. There was no difference in the duration of use of the rework program between the two groups, but a reduction in the meantime from leave of absence to daycare participation was observed: 274.5±106.0 and 210.6±228.5 days for the first and last groups, respectively.
Comparison of first 10 years group and last 5 years group
From these results, the following points merit discussion. First, bipolar II disorder and adult developmental disorders are recently accepted concepts, and there were no clear diagnostic criteria until the DSM-514) was published in 2013. When our daycare was established, the mainstream concept was refractory depression,15) which targeted workers who had repeated depressive phases many times and who returned to work only to have their symptoms recur and relapse soon after.16) Many of the users were middle-aged or older. Recently, with the spread of rework daycare, the number of users who participate after their first work absence has increased, users have become younger, and the number of female users has also increased. An increase in instances of depression resulting from workplace maladjustment in patients in the depressed phase of bipolar II disorder, which is considered to have a younger onset than major depressive disorder, and in patients with developmental disorder or its characteristics, was hypothesized17) but was not evident in this study. The time between absence from work and participation in daycare shortened, and there seemed to be a trend toward employers encouraging use of a rework program prior to a return to work, as their effectiveness in preventing recurrence of absence became more recognized.
Among the three types of prevention in occupational mental health, tertiary prevention aims to support the return to work and readjustment to the workplace of those with mental health problems. Although the government has provided guidelines on support for returning to work, there are many issues in determining whether a person is ready to return to work, indicating the importance of examining rework readiness from a medical standpoint.
In an effort to increase rework readiness, rework programs are being implemented at medical facilities nationwide. The evidence of relapse prevention was explained above.
The implementation of the rework program at the Toho University Sakura Hospital and the system of collaboration with attending physicians and workplace/occupational physicians was outlined above.
The diversity of depression pathologies has become apparent in recent years, and there is a growing need to develop programs tailored to the individual characteristics of users. At the same time, support not only for the return of workers with mental health problems to the workplace but also for their continued employment and job security are also future issues.
Conflicts of interest: None declared.
1978-1984 Toho University School of Medicine
1984-1988 Toho University Graduate School of Medicine
Professional Experience1988-1995 Assistant Professor, Department of Neuropsychiatry, Toho University Omori Hospital
1995 Senior Lecturer, Department of Neuropsychiatry, Toho University Omori Hospital
1995-1996 Research Fellow, Department of Psychiatry, University of British Columbia
1996-1999 Senior Lecturer, Department of Psychiatry, Toho University Sakura Hospital
1999-2001 Senior Lecturer, Department of Psychiatry, Toho University Ohashi Hospital
2001-2003 Director, Department of Psychiatry, Tokyo Rosai Hospital
2003-2008 Senior Lecturer, Department of Neuropsychiatry, Toho University Omori Hospital
2008-2013 Associate Professor, Department of Psychiatry, Toho University Sakura Hospital
2013-2017 Associate Professor, Department of Psychiatry, Toho University Sakura Medical Center
2017-2024 Professor, Department of Psychiatry, Toho University Sakura Medical Center
Board Certification2002 Japanese Society of General Hospital Psychiatry-Certification #73
2007 Japanese Society of Psychiatry and Neurology–Certification #62,012,997
Research Interests1. Consultation-Liaison Psychiatry
2. Occupational Mental Health
3. Transcultural Psychiatry
