This study assessed adherence to medication after liver transplantation and consisted of 2 components: a retrospective audit involving the examination of the Scottish national database, and a preliminary study assessing psychological factors implicated in poor adherence. In order to first establish an idea of the extent of poor adherence within the Scottish liver transplant population, a retrospective audit was carried out on all patients (N = 435) who received transplants before November 2003. Adherence was assessed by attendance at follow-up clinic appointments, blood immunosuppressant levels, and episodes of cellular rejection. It was found that attendance and immunosuppressant levels were often suboptimal and that nonadherence may have contributed to retransplantation and death. Cellular (acute) rejection after 6 months was associated with higher mortality. Explanations as to why liver transplant patients may not take their medication as recommended were then explored in detailed psychological assessments of 33 liver transplant recipients. The results indicated that low self-reported patient adherence was related to greater concerns regarding the potential adverse effects of medication, and a stronger belief that medicines in general are harmful. In addition, the greater the effect the transplantation had on patients' lives and the more it affected them emotionally, the less adherent the patients were likely to be. The results highlight potential areas that, if confirmed in a larger study, might be targeted in a psychological intervention to improve patient adherence and thereby transplantation outcomes. Liver Transpl 12:1862-1868, 2006. © 2006 AASLD.