Although there have been unexpected and unintended consequences - and what many might consider inadequate care - America has consistently attempted to care for its mentally ill. This article provides a historical review of the pathways this care has taken, with particular focus on the persistent inequities older and rural adults experience with regard to mental health care. The care of people with mental illness has taken different forms as social, political, and economic environments have changed. The persistent social construction of myths about aging in rural areas and ageist biases necessitate greater advocacy if more equitable care is to be provided. This will unquestionably involve addressing the myths surrounding rural life, removing the stigma attached to mental illness, becoming aware of the biases inherent in current service delivery systems, and developing new and different models for the delivery of care that is appropriate to diverse, rural settings.