This manuscript reviews the unique challenges, barriers, and ethical implications of providing mental health services in rural and underserved areas. Community mental health centers in rural areas are often underserved due to shortages of mental health providers and limited resources. Individuals living in rural areas are at increased risk of developing mental health condition with limited access to mental health clinicians and healthcare facilities. These access to care issues are often exacerbated by geographical barriers as well as social, cultural, and economic challenges. A rural mental health professional may encounter several barriers to providing adequate care to individuals living in rural areas. For example, limited services and resources, geographic barriers, conflict between professional guidelines and community values, managing dual relationships, and challenges pertaining to confidentiality and privacy are several barriers to providing adequate care in rural areas. We will briefly summarize the primary ethical domains that are especially influenced by rural culture and the complex responsibilities of mental health providers in rural areas including barriers to care, crisis intervention, confidentiality, multiple relationships/dual roles, limits of competency, and rural mental healthcare practice implications.