["The Journal of Rural Health, Volume 42, Issue 2, Spring 2026. ", "\nABSTRACT\n\nPurpose\nRural Veterans with serious mental illness (SMI) encounter significant barriers to accessing mental health care, related to SMI symptoms and rurality. A 2023 Government Accountability Office report found that rural Veterans used Veterans Health Administration (VHA) intensive mental health care for SMI less than urban Veterans relative to their population distributions. Our purpose was to deepen understanding of rural–urban differences in use of VHA mental health care among Veterans with SMI.\n\n\nMethods\nUsing VHA databases, we conducted a retrospective cohort analysis of 387,477 Veterans diagnosed with SMI, examining rurality as a predictor of intensive care for SMI and other outpatient mental health services.\n\n\nFindings\nOf 387,477 Veterans with SMI in VHA care in FY18‐FY22, 28% were rural. Compared to urban Veterans, a greater frequency of rural Veterans had mental health comorbidities including anxiety and posttraumatic stress disorder. Despite a higher burden of mental health conditions, rural Veterans with SMI had lower odds of receiving SMI care (38%), a video‐to‐home telehealth mental health encounter (15%), an outpatient mental health encounter (13%), and multidisciplinary care (10%). These findings remained after accounting for key potential exploratory factors. Older age, White race, non‐Hispanic/Latino ethnicity, being male, being widowed, and not having service connection were linked to lower odds of receiving later mental health care in unadjusted models.\n\n\nConclusions\nRural Veterans with SMI use VHA mental health care less than their urban counterparts. Given that VHA offers Veterans robust, specialized mental health services for SMI, research urgently needs to identify effective strategies for addressing barriers rural Veterans with SMI might face in using VHA‐delivered mental health care.\n\n"]