John Howard Lutz, now 76, has been locked up ever since the 2002 fatal stabbing of Nicole Castro. But because of his paranoid schizophrenia, the one-time physician has never gone to trial. (Montgomery County Police)

Nearly 13 years ago, John Lutz was accused of attacking a mental health counselor who had arrived at his apartment in Montgomery County for a noon therapy session. He stabbed her in the face, neck, arms and hands, according to police, before he wrapped her body in a pair of bedsheets, carried it outside and left it next to a trash bin.

Lutz, now 76, has been locked up ever since. But because of his paranoid schizophrenia, the onetime physician has never gone to trial.

That stands to change, based on a written order this week by a Montgomery judge who ruled that, among other factors, anti­psychotic drugs have helped Lutz better understand his surroundings. Lawyers in the case are due in court Friday to schedule hearing dates.

“He is not delusional and does not suffer from auditory or visual hallucinations,” Circuit Court Judge Ronald Rubin wrote, describing Lutz as a well-behaved patient at a maximum-security psychiatric hospital in Maryland. “The defendant is not, and has not been, a management problem.”

The case, in the extreme, shows the challenges faced by doctors, lawyers and judges as they sort through whether a mentally ill defendant is “competent” to understand court proceedings, talk to his or her lawyer, and face trial.

For seven years, starting in 2002, doctors said Lutz was incompetent. That opinion changed, briefly, in 2009, before Lutz was again declared incompetent.

Then, in late 2012, a doctor opined that both conditions were possible: Lutz’s competency would depend on the defense he pursued.

Judges such as Rubin have the ultimate say. After reading the 2012 report, Rubin ruled Lutz incompetent, saying he wanted to see more evaluations — and setting the stage for a recent court hearing and his ruling.

“It certainly is true that the defendant’s mental status has waxed and waned, and that various doctors, at various times, have reached differing conclusions,” Rubin wrote. “The important question for the court, however, is whether he is competent today to stand trial.”

The judge ordered Lutz to be served with a copy of his murder indictment and set him on the path for a trial as soon as next year.

Experts such as Larry Fitch, a University of Maryland law school instructor, said one key indicator in competency cases­ is how well a defendant can communicate with his or her lawyer. The Lutz case “speaks to how patients can go in and out of competency, depending on their symptoms and their response to treatment,” said Fitch, who until recently headed the forensic services division of the state mental health agency.

To family members of victims, the combination of differing opinions and legal limbo has been devastating.

“My world can be divided between my life before March 21, 2002, and my life after that,” the mother of victim Nicole Castro told Rubin in court last week, recalling her daughter’s commitment to her work. “She was a kind, loving young woman who became a social worker because she wanted to help people.”

The morning of March 20, 2002, Nicole Castro drove a Chevrolet Cavalier to Lutz’s apartment in Montgomery’s White Oak area. The onetime internist, then 64, had a long and significant history of mental illness, having formerly been hospitalized in a psychiatric facility west of Baltimore.

It isn’t clear from court records what authorities think prompted Lutz to allegedly beat and stab Castro. Her body was found early the next morning, less than 100 yards from Lutz’s apartment.

Police went to the apartment, knocked and heard movements inside but got no answer. They got a search warrant and found Lutz, a fresh bloodstain under his sofa and a key to the Cavalier, with blood spatter on the key ring.

Lutz’s mental health quickly became an issue, setting off a transfer from the county jail to the maximum-security Clifton T. Perkins psychiatric hospital.

For many years, according to court records, Lutz was deemed so strident in his defense strategy that it impeded his ability to talk with defense lawyers. He claimed that police didn’t have a valid search warrant, violated his Miranda rights and injected him in the neck with a mysterious truth drug.

In the spring of 2009, Lutz sent a two-page, handwritten letter to Circuit Judge Ann Harrington, recalling that among other topics on the day of his arrest. “One of the officers pressure injected my postero-lateral cervical trapezius fossa with a drug,” Lutz wrote. “There were ten injections on the right side, nine injections on the left side. As a consequence, I was mentally impaired and suggestible.”

Two months later, doctors at Perkins noted that Lutz seemed more open-minded about his defense. “Lutz’s thinking has become more flexible, in terms of his ability to work with an attorney, and the possibility that he may be convicted,” the doctors wrote, opining that he was competent.

But the position didn’t last long, according to court records, as Lutz slipped back into incompetency. That changed, slightly, in late 2012, when Lutz was evaluated. He was pleasant and scored well on a cognition exam. He could name the current U.S. president and spell the word “world” backward.

But Lutz was disheveled, with long, unwashed hair. He moved slowly behind a walker.

As for the criminal case, he was guarded but spoke about Castro. “I feel sorry for her and the people she left behind,” Lutz said.

He denied killing Castro but then said: “I must have done it. She was in my apartment. I was the only one there. I’m sorry. I don’t kill people.”

The evaluating psychiatrist, Danielle Robinson, wrote that if Lutz pursued a strategy of “not criminally responsible” — meaning he was so insane at the time of the killing that he didn’t know he was committing a crime — he would be competent. But if Lutz went to trial saying he’d been sane, that would make him incompetent.

Rubin, the judge, studied the report, questioned the doctor and ruled Lutz was incompetent, saying he wanted to revisit the issue in 2014. In December, Robinson evaluated Lutz, finding he was suffering from “unremitting psychosis” and noting that he had fallen back to a more rigid defense strategy.

Rubin wasn’t convinced, saying there wasn’t much new in Robinson’s report. Lutz’s belief in the neck injections, the judge noted, could have been the result of police having used a device such as a stun gun. In the end, Rubin said, Lutz seemed capable of sorting out such matters with a lawyer.

“He’s going to trial,” the judge said.