Background: Race is a social construct reflecting broader systemic forces that can affect health, including mental health. We sought to ascertain whether patterns of mental health care service use are associated with race among adolescents in Ontario.

Methods: We conducted a cross-sectional study using data from the 2015–2019 Ontario Student Drug Use and Health Survey. We assessed mental health care access for students in grades 7–12 younger than 20 years based on their responses about their care usage in the past 12 months. We used logistic and Poisson regression models to analyze differences in service utilization, with interaction terms for sex and mental distress (measured using the Kessler Psychological Distress Scale–6 Items).

Results: Black male students with low distress were nearly twice as likely as white males to report initiating care (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09–2.06). However, when Black males’ distress worsened to moderate levels, they became less than half as likely to access care than their white peers (OR 0.41, 95% CI 0.20–0.84). Black females faced disparities at all distress levels, with the gap widening as distress increased (moderate distress OR 0.78, 95% CI 0.46–1.34; serious distress OR 0.60, 95% CI 0.40–0.89). Even after initiating care, Black females mostly had lower odds of access frequency than white females (low distress OR 0.78, 95% CI 0.66–0.92; moderate distress OR 1.00, 95% CI 0.84–1.19; serious distress OR 0.60, 95% CI 0.42–0.85).

Interpretation: Black survey respondents with psychological distress were less likely to report using mental health services than their white peers, with Black female respondents being the least likely to access care. Policy and practice should seek to address systemic racism and a lack of culturally relevant care for Black adolescents with mental distress.