The purpose of this research paper was to highlight the factors students and school staff identify as contributors to mental health issues students attending rural, low socioeconomic high schools experience and the specific mental health issues they witness most. A collective case study was conducted in four rural high schools, two in Kansas and two in West Virginia. Field work at each school involved observations, document collection, and semi-structured focus group interviews with students and school staff. The factors identified as contributors to poor student mental health were pressure, technology, home life, bullying, and stigma. Anxiety, stress, depression, lack of health coping, and suicidal comments emerged as the specific mental health struggles students deal with the most. Recommendations for practice include practical ways to address the identified contributors of poor student mental health in rural schools and strategies to normalize mental health in the rural school environment.