Suicidal behaviour in the child and adolescent population presents specific clinical and psychosocial characteristics that clearly differentiate it from adults. In our sample, minors attended after a suicide attempt represented 8% of the total, with a female predominance (83% vs. 61% in adults) and a mean age of 15.3 years vs. 43.5 years. They showed a higher prevalence of childhood-onset disorders and EDs, while depression, anxiety, and personality disorders were similar in both groups. Substance use clearly differentiated the groups: alcohol, cocaine, and polysubstance use in adults, THC in minors. Adolescents used more cutting and firearms, although with lower lethality, whereas adults used sedative drugs, with higher lethality.

Recurrence was faster in minors, although the overall percentage of repeat attempters was similar between adults and minors. High-recurrence profiles showed clear differences: minors were characterized by a predominance of females, THC consumption, and adjustment disorders, whereas in adults, alcohol use, polyconsumption, and depressive or personality diagnoses were more prominent. Suicidal ideation was similar ($\sim$25%) and no minor died, compared with 106 deaths in adults, 38.6% by suicide. However, the absence of observed deaths in the minor group should be interpreted with caution due to the sample size (n = 153), as it does not imply an absence of mortality risk in this population. These findings reflect clear differences by age, sex, diagnosis, and consumption, highlighting adolescence as a period of critical vulnerability.

In our sample, we found among minors attended after a suicide attempt a clearly higher female prevalence in the adolescent population (83% vs. 61%), which is consistent with the international literature, which highlights the predisposition of adolescent girls to ideation and non-lethal attempts, while lethality tends to predominate in adult men [31, 32].

Numerous international studies show that suicide risk increases progressively throughout adolescence and reaches its maximum in young adults, with lower rates in preadolescent children [1, 2, 33]. This finding places adolescents at the peak of vulnerability for suicide attempts and coincides with international data showing an increase in the incidence of attempts between ages 10 and 17 [3, 31, 34].

In our sample, the proportion of foreign patients was slightly higher in minors (20.2%) than in adults (16%), but this difference did not reach statistical significance. This suggests that, in our context, immigration is not a relevant differential predictor of suicidal behaviour, in line with observation from countries with similar demographic patterns [35]. It is worth considering the demographic characteristics of the province of Lérida, where according to data from the Statistical Institute of Catalonia [25], in January 2023 there were 88,356 people of foreign nationality, representing approximately 19.75% of the total.

According to the literature, the profile of the minor patient with a suicide attempt is characterized by a female predominance, adolescence, the presence of depressive disorders, ADHD, and emotional difficulties inherent to development, as well as a significant influence of family and school factors [1, 36]. An emerging consumption of THC, the use of low-lethality methods, and early recurrence are also described in the literature [37, 38]. Our results coincide with this pattern: female predominance, greater presence of childhood-onset disorders and EDs, THC use, low-lethality methods, and rapid recurrence.

In our sample, minors showed a higher prevalence of childhood-onset disorders and EDs while the prevalence of unipolar depression, anxiety, and personality disorders was similar in both groups. This reflects that the psychiatric factors associated with ideation and suicidal behaviour are shared in both populations, but disorders such as ADHD, autism spectrum disorders, and EDs constitute more relevant factors in minors, in agreement with international findings [3, 4, 32].

Previous studies show that substance use increases the risk of suicide and recurrence [39, 40]. The literature shows that in adults, alcohol, cocaine, and polysubstance use predominate [41], whereas in adolescents, THC is more strongly associated with ideation and suicide attempts [42, 43]. Our data reflect this as well, showing that in minors with high recurrence. Our results specifically demonstrate that THC use was particularly relevant, while in adults alcohol, cocaine, and polysubstance use predominated.

International studies describe a consistent pattern: adolescents use more violent but less lethal methods, whereas adults, especially men, use more lethal methods such as firearms [34, 44, 45]. A striking finding in our cohort was a “lethality paradox” among minors: despite using more violent methods, their attempts showed low medical severity. Cutting was the most representative example (15% vs. 5.3%), a method frequently linked to emotional dysregulation and impulsivity rather than high suicidal intent. This overlap with non-suicidal self-injury underscores the importance of careful clinical assessment in adolescents. Notably, firearm use was more prevalent among minors than adults (2.6% vs. 0.6%), a concerning finding given its high lethality potential that reinforces the relevance of means restriction strategies in this age group [46, 47]. In contrast, adults more frequently used sedative drugs (43.7% vs. 33.3%). This pattern is consistent with the literature, which suggests that methodological violence in adolescents does not necessarily translate into mortality [1, 44, 45]. However, this should be considered a hypothetical explanation or possible mechanism rather than a definitive conclusion, as our data do not include direct measures such as injury location, weapon type, or failed attempts. It may be attributed to possible mechanisms such as impulsivity, low lethal intent, or limited planning. In adults, high-lethality methods were associated with higher mortality, consistent with established definitions integrating method potential and objective circumstances of the attempt [48].

The literature shows differences by gender and age in patterns of recurrence and lethality in suicide attempts, with higher frequency of attempts and recurrence in young adults, and increased lethality from age 45 onward [49]. In minors, the history of previous attempts is lower, and recurrence occurs more rapidly if they do not receive specialized intervention [1, 2, 33]. In our cohort, minors had fewer antecedents but recurred in a shorter time. While our model adjusts for several clinical phenotypes, the accelerated recurrence in minors may be deeply influenced by unmeasured psychosocial factors, such as family instability or school-related stress, which were not available in our database.

The finding of accelerated recurrence in minors has direct clinical implications for post-emergency management. Standard follow-up periods may be insufficient for this vulnerable group [50]. We propose the implementation of “rapid response” protocols, ensuring a clinical contact (either in-person or via tele-psychiatry) within 48–72 hours after the emergency department visit. This early intervention should prioritize three core pillars: first, the review and reinforcement of safety plans; second, the active restriction of access to lethal means [46], which is particularly critical given the high prevalence of violent methods like cutting and firearms observed in our underage sample; and third, the early detection of relapse symptoms [37]. A well-established model for this approach is the Catalonia Suicide Risk Code (CRS) [51, 52]. According to Pérez et al. [53] the CRS immediate follow-up actions include a face-to-face appointment within 10 days for adults and 72 hours for minors, as well as a telephone contact at 30 days of enrolment. While this model has proven effective in our region, its applicability to other healthcare systems would require careful adaptation to local resources and clinical workflows.

Among patients with high recurrence ($\ge$3 attempts) after the index attempt (24.1% adults, 23.5% minors), minors were mostly female, with predominance of THC use and adjustment disorders, while adults showed predominance of alcohol, polysubstance use, and major depression, according to findings by other researchers [43, 54, 55]. We found that overall lethality was higher in adults, although some subsequent attempts in recurrent minors reached greater severity. These findings underscore consistent differences by gender, age, and type of diagnosis in the recurrence and lethality of suicide attempts [3, 31, 45]. Due to the sample imbalance, these results should be replicated in larger, more balanced multicenter studies to confirm the stability of the age-related hazard.

In summary, these findings suggest an association between underage status and a pattern of rapid recurrence; however, this should be interpreted as a regional clinical phenotype rather than a stable independent effect. Unmeasured psychosocial factors, such as family instability or school-related stress, likely contribute to this pattern, and the observed sample imbalance (reflecting the real-world epidemiology of our health region where minors represent a smaller proportion of psychiatric emergencies) may also influence the results. Therefore, further studies in larger and more diverse cultural and healthcare contexts are needed to assess the generalizability and stability of these patterns.