PURPOSE In low and middle-income countries, about 80% of those who need mental health services do not receive them. Reasons for this have not been systematically studied. In this qualitative study, we explored this issue in a rural community of South India among schizophrenia patients. MATERIALS AND METHODS Patients who had never sought psychiatric treatment despite long-standing psychotic illnesses were identified as part of a community intervention program. In-depth interviews were conducted with patients' caregivers to understand factors preventing them seeking psychiatric treatment. Interviews were audio-recorded and transcribed. Reasons cited by family members were listed and grouped into factors based on themes. Interview process was iteratively followed till no new factor emerged. Sixteen caregivers were thus interviewed. RESULTS Content analysis brought out 75 reasons, which were further grouped under the following 15 factors [n (%)]: Lack of awareness about the illness: 15 (93.75%); lack of family support: Nine (56.25%); religious attributions: Nine (56.25%); financial constraints: Six (37.5%); family dynamics: Seven (43.75%); family's tolerance: Seven (43.75%); lack of insight: Five (31.25%); families resilience: Four (25.0%); community beliefs regarding mental illnesses: Four (25%), and others. In each patient, a complex interplay of several of these factors precluded the family from seeking psychiatric treatment. CONCLUSIONS In addition to the well-known factors, many hitherto less-understood factors (e.g., families' conflicts, dynamics, resilience and acceptance, and community support, etc.) were identified which prevented patients and their families from seeking treatment. These findings have important policy implications.